Insurance Claims Management for Health Claim Leakages

The Challenge

The customer had legacy IT infrastructure with multiple system integrations. Lack of validations during insurance claims processing led to claims leakage. Manual processing of claims consumed more time. The customer was heavily dependent on TPAs for claims processing. health insurer was seeking a system which could give them more control over the TPA and enable transparency. The customer wanted to bring in-house part of the insurance claims processing.

The Solution – Automated Insurance Claims Processing to Reduce Claims Leakage

iNube implemented a system with flexibility for both TPA and Insurance company to process claims.

  • End to End Health Claims Management Solution from enrolment of members to settlement of claims was implemented
  • Exhaustive product configuration module to enable customer to introduce product offerings
  • Custom built workflows to incorporate TPAs using own system to upload data at strategic points during claims processing via a front-end interface (TPA Portal)
  • Capability to map Provider SOC and tariff against unique Service Codes was done to enable digital validation of claims
  • Business Rule Engine to flag duplicate claims, insufficient BSI, package mismatch etc.
  • ICD 10 based configuration of benefits, covers to enable auto adjudication of claims

In conclusion, the health insurer faced challenges with their legacy IT infrastructure and manual processing of claims, resulting in claims leakage and dependence on TPAs. iNube implemented an end-to-end health claims management solution that enabled flexibility for both TPA and insurance company to process claims. The solution included a custom-built workflow to incorporate TPAs, digital validation of claims through mapping of provider SOC and tariff, a business rule engine to flag duplicate claims and insufficient BSI, and ICD 10-based configuration of benefits to enable auto adjudication of claims. This solution gave the health insurer more control over the TPA and enabled transparency, while reducing claims leakage and manual processing time. Overall, the implementation of the automated insurance claims processing system proved to be a successful solution for the customer.



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