Unlocking Business Value with Process Orchestration in Healthcare Payers

Introduction?

This is Part 8 of my Unlocking Business Value series. See also articles for Financial Services, Insurance, Public Sector, Nonprofits, Manufacturing, Telecommunications and Retail.?

Today’s healthcare industry grapples with complex challenges like regulatory changes, cost pressures, and an increasing need for personalized care. To remain competitive, healthcare payers need to embrace strategies that enhance efficiency, improve customer experiences, and give them a competitive edge.? Automation is a clear strategic imperative that aligns to these goals.? Process Orchestration is an ideal way to realize the imperative to automate core business processes, transform how payers operate, and gain significant competitive advantage.??

In this article, we will take a closer look at why process orchestration is so important and transformative for payers, discuss some real-life examples and outcomes, take a deeper look at a common use case, and discuss the impact of scale on value delivery.

We need approaches to the solutions that aren’t just arithmetic and additive, but are in some sense logarithmic. This will require us to reach across historic boundaries and unlock the potential of collaboration across the usual disciplines. -Jeffrey S. Flier, MD, Dean of the Faculty of Medicine, Harvard University

The Value of Process Orchestration

Process orchestration brings significant business value to healthcare payers in several categories:

1. Operational efficiency: Process orchestration streamlines and accelerates administrative tasks, such as claims processing, billing, and enrollment. This reduces manual errors, speeds up turnaround times, and frees up staff to focus on more complex and value-added activities.??

2. Cost savings: Process orchestration and rules engines offer significant value in terms of cost savings. By automating repetitive and time-consuming processes, healthcare payers can reduce operational costs associated with manual labor, paper-based systems, and rework caused by errors. Camunda, with its strong focus on ease of development and integration, enables seamless, end-to-end, task and data flow across systems and departments, simplifying the integration of disparate systems and reducing project complexity. Rules engines allow organizations to centrally define and enforce business rules, making it easier to adapt and modify automation processes as business requirements evolve. By leveraging these capabilities, payers can streamline operations, improve efficiency, and quickly adapt to changing needs, resulting in significantly improved financial performance and long-term cost savings.? At scale, these savings can translate into many millions of dollars.?

3. Accuracy and compliance: Healthcare is a highly regulated industry and healthcare payers often face challenges in complying with changing regulations.? Automated processes minimize human errors and ensure consistent, documented adherence to regulations and compliance requirements.? This reduces the risk of penalties, audits, and legal issues, enhancing the overall risk posture.

4. Enhanced customer experience: Process orchestration enables faster response times, better omnichannel customer journeys, and improved accuracy in handling member inquiries, claims, and other customer-related processes. Call centers, when utilized, can be significantly more efficient with end-to-end process orchestration.? All of this results in higher customer satisfaction and loyalty.

5. Data-driven insights: Process orchestration facilitates the collection, analysis, and utilization of very useful data about core business processes. Processes automated with Camunda are automatically instrumented and resulting data from their execution is automatically collected.? By leveraging advanced analytics and reporting tools such as Camunda Optimize, payers can gain valuable insights into member behavior, cost patterns, and healthcare trends. These insights can inform decision-making, risk management, and the development of more targeted and effective healthcare strategies.??

6. Agility: Historically, Mergers and Acquisitions (M&A) have driven growth in the healthcare payer industry.? This has also led to a proliferation of silos within many of these organizations, as each entity involved usually brings its own set of processes, systems, and data repositories. These disparate systems often remain separate, creating silos that can hinder communication, collaboration, and data sharing, leading to inefficiencies, redundancies, and errors.? Combining these silos in new ways to address evolving needs of the business and empower innovation can pose significant challenges.? Process orchestration can be a powerful solution to this problem.? An “end-to-end” scope of automation that efficiently spans silos is a defining characteristic of process orchestration. It can also provide a holistic view of the organization's core business operations, enabling better decision-making and strategic planning, offering a unique solution to the integration of silos resulting from M&A activity.?

Camunda customers see up to a 3.5x reduction in error rates and greater than 98% reduction in time to complete manual tasks, with commensurate savings and improved satisfaction measurements.? Additionally, Camunda customers implement their automation up to 3x faster than other approaches to automation.??

Let’s discuss some of the common use cases that yield these business outcomes.?

Top Use Cases for Healthcare Payers

Here are some top use cases for process automation:

1?? Member Enrollment: Process orchestration simplifies the member enrollment process, from application to approval, across one or multiple channels.? It can automatically verify applicant information, determine eligibility, and generate member IDs, reducing administrative workload and improving member experience.? Omnichannel onboarding is a frequently seen use case for Camunda.?

2?? Claims Processing: Process orchestration can significantly speed up the claims process, reducing manual errors and improving efficiency. This includes automatic verification of patient eligibility, coding, billing, and adjudication, leading to faster and more accurate payments.

3?? Pre-Authorization: Process orchestration can streamline the pre-authorization process, reducing delays in care and ensuring conformance with care guidelines. By automatically checking patient eligibility, treatment protocols, and insurance coverage, healthcare providers can quickly receive authorization for necessary treatments or identify exceptions needing special handling and ensure appropriate outcomes.?

4?? Fraud Detection: Process orchestration can help identify fraudulent claims more quickly and accurately by leveraging configurable business rules, AI and other mechanisms. By analyzing patterns and anomalies in claim data, automated systems can flag potential fraudulent activity for further investigation, helping to protect healthcare payers from financial loss.??

5?? Provider Data Management: Process orchestration can streamline the management of provider data, including credentialing, contract management, and maintaining up-to-date provider directories. This can enhance accuracy, reduce administrative burdens, and improve provider relationships.

6?? Payment Reconciliation: Process orchestration can simplify the reconciliation of payments received from various sources, ensuring accuracy and timely recording. This can help avoid discrepancies, reduce administrative efforts, and improve financial accuracy.

7?? Care Coordination: Process orchestration can streamline the coordination of care among various providers, ensuring seamless communication, timely sharing of patient information, and efficient scheduling of appointments and procedures. This can enhance patient experience, improve care delivery, and reduce healthcare costs.

These are just a few examples of how process automation can be used by healthcare payers to improve efficiency, accuracy, and customer satisfaction, while reducing costs and risk.? For more guidance on where to focus automation efforts, see Identifying Candidate Processes for Automation.

Let’s take a deeper look at one of these use cases.?

A Deeper Dive into Claims Processing?

The claims process is an ideal target for process orchestration due to its inherent complexity, high volume, regulatory importance, need for data integration, and impact on customer satisfaction. This process involves multiple steps, from initial filing to final adjudication, often across different departments and systems. Payers typically handle a large volume of claims daily, which will amplify the value of any efficiency gains.? Compliance to various regulatory guidelines is also necessary, and process orchestration can ensure consistent application of these rules.? Additionally, claims data, often scattered across different silos, can be integrated through process orchestration, providing a unified view for better decision-making and improved patient care.??

A generic claims process for a healthcare payer can be represented using the following Business Process Model and Notation (BPMN).? This is an open standard that uses an easy to understand, graphical representation for specifying business processes in a workflow, making it easier to understand the process and improve its efficiency.? One key value of this approach is that the process can (should) be co-developed between business and IT and the model that ultimately results is the same one that runs in production.? This cross functional collaboration is a fundamental design consideration for Camunda Modeler, the tool that produced this model.?

Here is a high-level description of the process:

1. Start Event: The process begins when a member initiates a claim submission through any available channel (e.g., online portal, mobile app, phone call).
2. Receive Claim Information: Our payer collects the necessary claim information from the member, including details such as the nature of the claim, relevant medical documents, and supporting evidence.
3. Validate Claim Information: The collected claim information is validated for completeness, accuracy, and adherence to predefined criteria. This step may involve verifying the member's eligibility, reviewing the submitted documents, and checking for any missing information.
4. Assign Claim Reference Number: A unique claim reference number is assigned to the submitted claim for tracking and identification purposes.
5. Assess Claim Eligibility: The payer assesses the claim's eligibility based on predefined criteria, such as coverage policies, plan limitations, and medical necessity.? This is accomplished in our model with business rules.? These are defined using an open standard, Decision Model and Notation (DMN).?
6. Adjudicate Claim: The claim is processed and evaluated for payment determination. This step involves reviewing the claim against the payer's coverage policies, fee schedules, and any applicable contractual agreements.
7. Determine Payment: The payer determines the payment amount based on the adjudication results, including factors such as covered services, deductibles, co-pays, and any applicable limits or exclusions.
8. Generate Explanation of Benefits (EOB): The system generates an Explanation of Benefits (EOB) statement, detailing the payment determination, covered services, member responsibility, and any additional information or instructions.
9. Process Payment: If the claim is approved for payment, the payer initiates the payment process, which may include disbursing funds to the healthcare provider directly or reimbursing the member according to the payment method agreed upon.
10. Communicate to Member: The EOB statement is communicated to the member through their preferred channel(s) of communication, such as email, secure online portal, or physical mail.
11. Update Claim Status: The system updates the claim status to reflect the adjudication outcome, whether it is approved, denied, or pending further review.
12. Await Reply: Members have 14 days to appeal claims decisions.? If an appeal is received, return to Validate Claim Information.?
13. End Event: The process ends, and the claim submission process is completed.

Candidate KPIs

Key Performance Indicators (KPIs) are critical in process orchestration as they provide measurable and quantifiable benchmarks for evaluating the effectiveness and efficiency of business processes. By monitoring these KPIs, businesses can identify areas of improvement, optimize operations, and align their processes with strategic objectives, driving overall business growth and success.

Camunda automatically instruments the processes it orchestrates and makes available a very complete set of process metrics, some of which are possible KPIs.? For more information about KPI selection, see Driving Business Success: Setting KPIs for Process Orchestration Projects.??

For our claims process, let’s review some candidate KPIs that could be used to measure performance:

?? Claim Processing Time: Measures the average time taken to process a claim from submission to payment determination. This KPI helps assess the efficiency and speed of the claims process.

?? Claim Cycle Time: Measures the average time taken for a claim to move through the entire claims process, from submission to payment determination. This KPI helps evaluate the overall efficiency and effectiveness of the claims process.

?? Claim Accuracy: Measures the percentage of claims that are processed accurately without errors or discrepancies. This KPI reflects the quality and accuracy of claim processing.

?? First-Time Claim Acceptance Rate: Measures the percentage of claims that are accepted and approved for payment without requiring any additional information or resubmission. This KPI indicates the effectiveness of claim validation and reduces the need for rework.

?? Claim Denial Rate: Measures the percentage of claims that are denied or rejected. This KPI helps identify potential issues in claim eligibility, documentation, or adherence to coverage policies.

?? Member Satisfaction: Measures member satisfaction with the claims process, typically through surveys or feedback mechanisms. This KPI reflects the overall member experience and perception of the claims service.

?? Provider Satisfaction: Measures provider satisfaction with the claims process, typically through surveys or feedback mechanisms. This KPI reflects the provider experience and perception of the payer's claims service.

?? Claims Frequency: This measures the number of claims made over a specific period. A high frequency might indicate a problem that needs to be addressed.

?? Cost Per Claim: Measures the average cost incurred by the payer to process each claim. This KPI helps assess the cost-effectiveness of the claims process and identify potential areas for optimization.

These KPIs provide insights into the performance, efficiency, accuracy, and member/provider satisfaction levels of the claims process, enabling the payer to identify areas of improvement and ensure a smooth experience for all stakeholders.? Ultimately, selecting which business KPIs to surface for these purposes is decidedly not an IT exercise.? Typically, the responsibility of KPI selection lies with the business process owners, as they have a deep understanding of the process, its objectives, and the desired outcomes. They work in collaboration with the executive team and other stakeholders to ensure the selected KPIs align with broader business goals.

Once we understand what candidate KPIs we have in mind, we can easily build dashboards that surface them to key stakeholders.

KPI Dashboards

Camunda Optimize is an advanced tool designed specifically for business users, enabling them to gain valuable insights for continuous process improvement. Any processes that Camunda orchestrates are automatically instrumented for use with Optimize. It offers a user-friendly interface that requires no coding skills, allowing users to configure custom dashboards and reports easily. With real-time data analysis, users can identify process bottlenecks and inefficiencies swiftly. Its simplicity in configuration, combined with its powerful analytical capabilities, empowers business users to make data-driven decisions, enhancing productivity, and driving operational excellence within their organization.??

A claims processing dashboard should provide a summary of relevant KPIs related to the claim processing workflow. It offers a visual representation of important data points to monitor and evaluate the efficiency and effectiveness of the process.? All of the potential candidate KPIs and many more metrics are available to create dashboards for processes running in Camunda.? To maximize their effectiveness, each dashboard should be tailored to the concerns of each stakeholder role. For example, one for Executives and another for Claims Managers.?

Let’s take a look at how we might surface some of these KPIs in Optimize dashboards.?

Executive Level Claims Process Dashboard?

Executives typically focus on high-level strategic objectives and overall organizational performance. Their KPIs may include metrics such as profitability, revenue growth, cost containment, customer satisfaction, and market share. They are interested in the financial health and competitiveness of the organization as a whole.

Claims Manager Dashboard?

Claims Managers are responsible for the day-to-day operations of claims processing. Their KPIs are more operational and focused on efficiency and effectiveness. Some common KPIs for Claims Managers may include claims processing time, accuracy of claims adjudication, claims denial rate, turnaround time for appeals, and customer service metrics. They aim to ensure smooth and timely claims processing while minimizing errors and improving customer satisfaction.

A Real-World Example?

Let’s consider a real world example of the value of process orchestration in a claims process.?

Amid a growing backlog of claims for pensions, Dependency and Indemnity Compensation (DIC), and burial benefits, the U.S. Department of Veterans Affairs partnered with Booz Allen Hamilton. The urgency for a solution was heightened by factors such as the Blue Water Navy legislation and the COVID-19 pandemic.? After a comprehensive market analysis, Camunda was selected as the process automation and microservices orchestration platform.?

Booz Allen developed a solution integrating machine learning and business process automation using Camunda, leading to a more than 65% increase in automation rate and a reduction in average claim processing time by over one third. They developed an automation engine to orchestrate legacy systems services and manual evaluation steps, augmented by a machine learning capability.? The new solution, which combined Camunda with agile development and DevSecOps, saved hundreds of hours of coding and enabled the creation of executive dashboards and operational reports providing full control and visibility into operations.?

Over the last year, Booz Allen delivered over 25 releases into production, significantly decreasing the average claim cycle time and the associated claims backlog. As a result, some claims are now decided within hours of establishment, accelerating the delivery of services to Veterans and their families.

Scaling Automation?

Process orchestration is a transformational approach that’s designed to address end-to-end automation and empower strategic, enterprise digital transformation.? As it is applied to more and more parts of a payer’s business, the value derived will not increase in a simple, linear, incremental fashion. Instead, the benefits often increase rapidly as the use of process orchestration increases within the organization.??

There are several factors that drive this value delivery function:??

1?? Efficiency: As more processes are automated, the overall operational efficiency of an organization increases. Tasks are completed faster and with fewer errors, leading to significant time and cost savings.

2?? Consistency: Scaling process orchestration ensures consistent application of business rules across the organization. This leads to standardized outputs, improved compliance, and reduced risk of errors or deviations.

3?? Reusability: Components can often be reused across different processes or departments. This reduces the time and resources needed for developing new processes, leading to faster implementation and higher return on investment.

4?? Integration: As process orchestration is expanded, it can easily integrate more systems and data sources. This enhances data flow and communication across the organization, leading to better decision-making and collaboration.

5?? Human Focus: With routine tasks automated, employees can focus on more strategic, higher value-added activities.?

6?? Agility: Process orchestration at scale allows payers to respond faster to changes in the business environment, be it market trends, customer demands, or regulatory changes. This agility can provide a significant competitive advantage.

7?? Customer Experience: As more customer-facing processes are automated and integrated, the customer experience improves. Faster response times, personalized interactions, and seamless multi-channel experiences can boost customer satisfaction and loyalty.

8?? Data Insights: Scaling process orchestration results in more data that can be analyzed for insights. These insights can drive strategic decision-making, improve process performance, and identify new opportunities.

Camunda’s Process Orchestration Maturity Model (POMM) is a strategic tool that assesses the value of process orchestration in an organization's automation efforts.? It provides a systematic approach to understanding an organization’s current level of process orchestration maturity and it codifies an important concept: process orchestration is not an all-or-nothing effort.? It is a journey.? The POMM identifies five drivers of process orchestration maturity: vision, motivation, team structure, measurement, and technology.? These help organizations identify key areas where they need to focus to maximize the value of their digital transformation investments.? As they advance through their maturity journey, they gain more and more benefits, yielding those non-linear dividends discussed above.?

Organizations often start with a single project or ad-hoc use case when beginning their journey towards process orchestration maturity.? Starting with a single, mission-critical process orchestration project allows organizations to focus on specific needs and understand how these efforts can drive further organizational value.? As they gain experience and see the benefits, they can then scale up to broader initiatives, eventually leading to organization-wide digital transformation goals.? It’s generally advisable to start with a project before moving on to a large, broadly applied, strategic program.

Real-World Example

In 2014, an insurance company with over 7,000 employees initiated a project to automate their manual claims handling process, which was spread across several isolated business units. The complexity of the existing system made it easy to secure management approval for the project, which was in line with the strategic initiative to enhance "process orientation". The project involved evaluating and implementing Camunda, modeling the process, integrating it with their current user interface and infrastructure, and exporting relevant data into their data warehouse.

After initial implementation, the project team transitioned into a department that assisted other teams in designing and developing process solutions. Initially, they performed much of the implementation work but eventually evolved into an internal consulting team, focusing on initiating other teams into process automation. They became the central point for all workflow tool-related queries, documented experiences and learnings, and facilitated knowledge sharing across the organization. They also ran an internal BPM blog, organized training classes, and held an annual event for sharing best practices.

By the end of 2019, the team had successfully implemented nearly 100 different workflow solutions in production, a feat that was well-received by both the workflow team and upper management. They developed additional tools on top of Camunda but did not mandate their use within the company.

Conclusion?

Process orchestration brings significant business value to healthcare payers, especially when implemented at scale. It enables streamlined workflows, improving efficiency, accuracy, and cost-effectiveness. Real-time data exchange and integration enhance agility, resulting in faster claims processing, better customer service, and reduced administrative burdens.

Payers can visualize process performance and KPIs and proactively address bottlenecks and inefficiencies by optimizing processes and implementing intelligent routing. This ensures timely and accurate claims processing, reducing errors, improving compliance, and enhancing customer satisfaction.

Automation through process orchestration frees resources and allows staff to focus on strategic decision-making, customer engagement, and innovation. By embracing automation as a strategic imperative and implementing end-to-end process orchestration, healthcare payers can lead their industry, navigate complexities, deliver exceptional value, and stay ahead in an evolving market.

Read more

Identifying Candidate Processes for Automation

Unlocking Business Value with Process Orchestration in Insurance

Camunda Optimize: Integrated process intelligence platform and analytics

Driving Business Success: Setting KPIs for Process Orchestration Projects.

Whitepaper: Scaling Process Automation at your Company

Case Study: “Months to minutes: VA speeds benefits services with automation”