CareOregon Implements HPA’s RPA-as-a-Service to Reduce Manual Intervention in Claims Processing
Founded in 1994, CareOregon is a nonprofit organization providing health insurance services to more than 375,000 low-income individuals in Oregon. CareOregon is a managed care company with a broad goal: to make world-class healthcare available to all Oregon residents, regardless of income. The plan has built a healthcare delivery system that assures member access to physicians and healthcare professionals who understand special needs and provide quality care. True to their mission, it also supports local programs that offer housing, food, and job training to all Oregonians.
As a Safety Net Health Plan, it operates as a 501(c)(3) that derives nearly all of its revenue from public programs like Medicaid (the Oregon Health Plan), Medicare and the State Children’s Insurance Program. CareOregon currently manages health plan services of three coordinated care organizations (CCOs) in Oregon, and operates a Medicare Advantage plan and a dental care organization. Its health plan services received a 3.5 STAR rating from CMS in 2019, and its drug plan services received 4 stars.
Applying Automation in Claims Management
Reducing administrative cost is a top concern for health plans. Human intervention can expose claims to human error and lengthen the claims lifecycle, both of which contribute to an increase in overhead cost. Lengthy cycle times are also a key contributor to claims backlog. CareOregon was experiencing similar struggles when they reached out to HPA in 2015 to begin automating claims processes. The plan currently has five automated processes in production with HPA and administers claims on the QNXT Enterprise Core Administration System by TriZetto. HPA is fully-interlocked with TriZetto on product upgrades, hosting needs, and enhancing overall quality of service delivery to clients.
Controlling costs, improving operational efficiencies, and reducing waste in the health care system is better for everyone, and a top priority for CareOregon. Our partnership with HPA enables us to apply more resources and focus towards fulfilling our mission to promote equitable healthcare for individuals and our communitiesAmy Dowd, Chief Operating Officer
Coordination of Benefits (COB) claims were selected as the initial target for automation at the beginning of CareOregon’s engagement with HPA. COB allows health plans to determine who is responsible for the payment when a member is covered by two different plans. A member’s benefits and reimbursement rate should not exceed 100 percent of allowed medical expenses, and examiners must ensure there are no duplicates in the system. COB claims are also paid or denied based on the Medicare plan, benefit plan, type of claim, and location of services rendered.
When manually processed by examiners, each COB took an average of 3 minutes. With an average monthly volume of around 5,600 COBs, CareOregon would have to spend more than $130,000 in overhead annually just to process this one claim type.
Since the automated process went live in November of 2016, the plan has saved over $300,000, as well as 3,700 manual hours annually, the equivalent of 3 full-time employees. Additionally, when CareOregon experienced a spike in volume due to increased Non-Emergency Medical Transportation submissions, HPA’s robots seamlessly scaled to the new volume, allowing the client to avoid backlog
Read the case study to learn more about CareOregon's RPA initiative and the incredible ROI results it has achieved through automation.