5 mistakes to avoid while solving manual adjudication problems through Pega Robotics

Hold claims or Pend claims pull down the efficiency of a Payer organization to a high degree. There is little reason to believe that Hold claims or Pend claims or manual adjudication problems will reduce in the near future, thanks to ever changing healthcare business rules and the high risk and efforts involved in fixing or configuring those rules into legacy codes.

Despite the heavy investment on claims IT by organizations, the percentage spent on claims processing keeps increasing. Currently, the percentage of manual adjudication across payers ranges from 15% to 45%; which is indigestible. This problem seems perennial and the issue leads to ancillary problems, such as the need to recruit increasing number of claims analysts, continual training on ever changing knowledge base, reduced effectiveness of dollars spent on training, etc.

However, the percentage of manual adjudication of claims can be brought down, drastically; thanks to Pega Robotics. Positioning a robot in the process and taking judicious decision to pick the hold codes for robotic automation plays a key role in the success of the solution.

  1. Don’t fail late

Like with any other IT implementation, it is better to fail early in robotic process automation too. Knowledge on the capability of the robots in accessing every necessary or possible touch point system at the screen level is necessary. A POC on the same will provide indications both on the feasibility as well as performance. This would definitely help in answering many of the questions which would crop up later in the project and that may potentially lead to last minute surprises.

  1. Don’t disrupt existing process
RPA - Claims processing flow

RPA – Claims processing flow

It is observed that most of the time businesses try to also include their long waiting wish lists, such as re-engineering the processes or workflows, etc into the robotics projects as wild cards. This approach should be a big NO, and businesses should avoid bringing in changes which are not core to the requirement at hand. Moreover, it is not a best practice for Pega Robotics to disrupt the existing business processes. Meticulous analysis is required to position Pega robotics in processes.

  1. No spreadsheets or FTP for work assignments

Novices in Pega Robotics would usually suggest to have work assignments to robots, which are to be stored in in spreadsheets or files in FTP-servers or other similar methods. The downside of this approach is that you would miss out on the benefits of the out-of-box capabilities available in Pega such as productivity dashboards, case assignments, routing, etc.

During the process of identifying how the cases can be fed or provided to robots, people usually recommend the above scenarios depending on the skills of the robot. However, the problem can be easily handled by leveraging Pega’s skill based routing capability to the designated workbasket or worklist. It also supports the process of incrementing the bot skills in a phased manner, from release to release.

  1. Don’t teach the bot to solve a problem which can be handled by OOB

There has to be a strong reason to automate every action by the robot. It is essential to leverage the out-of-box (OOB) capabilities of Pega Robotics rather than teach Pega how to do the job.

For example, it is recommended to send emails using Pega’s correspondence capabilities than to teach a bot to send emails using Outlook. It is further recommended to leverage the claims repair out-of-box capabilities to solve the post edit, rather than teach the robots how to solve it.

  1. Don’t under weigh the RPA candidate choosing process

Pega robotics has given guidelines on how to choose a candidate for robotic automation. In addition, it is recommended to perform a thorough analysis on identifying the candidate hold codes based on the volume of effort it takes to manually adjudicate versus the cost to fix the problem. This would also involve fees for usage of the systems.

Above all, the biggest mistake you should be avoiding is building a team with no Certified Pega Business Architects.


Let the robots make a better world.

Kuzhalan Samydurai

Manager - Business Consulting, Virtusa. Kuzhalan Samydurai has helped lead healthcare organizations for more than a decade by providing IT solutions for their complex business problems, enabling their growth and making them complaint with the industry regulations

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