RPA in Healthcare

Automated CMS-1500 and UB-04 claims preparation, EDI 837P/837I submission, status monitoring, and rejection management -- processing that currently takes 8-12 minutes per claim manually runs in under 60 seconds per claim with error rates dropping from 5-10% to under 1%. Bots extract patient demographics, insurance ID, diagnosis codes (ICD-10), procedure codes (CPT, HCPCS), and rendering provider NPI from your EHR (Epic, Cerner, eClinicalWorks, Athenahealth), populate payer-specific claim forms, and submit via your clearinghouse (Availity, Change Healthcare, Office Ally) or direct payer EDI connection. Clearinghouse acknowledgement (999/277CA) tracking confirms submission receipt; claim status queries (276/277) run on a configurable schedule so outstanding claims are monitored without manual portal logins. Rejected claims (835 remittance, CO/PR reason codes) are categorized by rejection type and routed to the appropriate staff member with the rejection code, the denial reason in plain English, and the specific claim data element that triggered the rejection -- so the resubmission step takes minutes rather than requiring the biller to research the reason code from scratch.

Automated prior authorisation request submission across payer portals -- the workflow that currently takes 20-40 minutes of staff time per request and introduces delays that postpone scheduled procedures and frustrate patients. Bots pull patient demographics, insurance information, diagnosis codes (ICD-10), procedure codes (CPT), and the required clinical justification documentation from your EHR; complete the payer-specific prior auth form on the payer portal (BCBS, UnitedHealthcare, Aetna, Cigna, and regional payers); and submit the request with all required supporting documentation attached. For payers that accept electronic prior auth via X12 278 transactions, we use the EDI channel for faster submission and structured status responses rather than portal UI automation. Status checking queries run on a configurable schedule (every 4 hours for urgent procedures, daily for elective) with escalation to the prior auth coordinator when an authorisation has not been received within the payer's published turnaround standard. Denied prior auths trigger an appeal workflow with the relevant clinical criteria and payer-specific appeal form populated from the same source data. The 30-minute manual process becomes a 5-minute exception-review process for complex cases; straightforward requests process without staff involvement.

Automated data entry from intake forms, referral documents, lab results, and external records into your EHR -- eliminating the manual transcription work that consumes medical admin time and introduces transcription errors. HL7 v2.x (ADT, ORU, ORM message types) and FHIR R4 API integration handles real-time data exchange between your EHR and connected systems (labs, imaging, pharmacy, referral partners) without manual re-entry. For sources that don't support structured interfaces (scanned referral letters, faxed lab results, PDF discharge summaries), OCR extraction pulls the relevant clinical data fields for staff to verify before posting -- reducing the data entry time per document from minutes to a 30-second verification step. Cross-system patient record reconciliation matches patient records across your EHR, billing system, and scheduling platform using probabilistic matching (name, DOB, MRN, insurance ID) to identify duplicates and merge conflicts before they compound. Bulk data migration for practice acquisitions or EHR transitions (Epic to Cerner, eClinicalWorks to Athenahealth) includes data mapping, transformation, validation, and reconciliation reporting to confirm migration completeness before the source system is decommissioned.

Automation across the full revenue cycle from patient scheduling to payment posting -- the end-to-end workflow where manual steps at each stage compound into extended days in AR (industry average: 40-50 days; optimised RCM: 25-30 days). Eligibility verification bots run EDI 270/271 transactions against payer databases 24-48 hours before each scheduled appointment, flagging coverage lapses, plan changes, or missing authorisations before the patient arrives rather than after the visit when collection is harder. Co-pay and deductible lookup presents staff with the patient's current balance at check-in. Post-visit charge capture automation applies CPT and modifier coding rules to encounter data before claim submission, reducing undercoding and overcoding errors that trigger audits or underpayment. Denial management workflows categorize 835 remittance advice denials (CO-4 coding error, CO-97 duplicate claim, PR-1 deductible, CO-45 contractual adjustment) and route each denial type to the correct rework protocol -- coding denials to the coding team, eligibility denials to the front desk, timely filing denials for appeal. Payment posting automation applies remittance advice adjustments to the correct patient account, identifies underpayments against contracted rates, and generates automated appeals for payment variances above a configurable threshold.

Automated assembly of compliance reports from data across multiple clinical and administrative systems -- eliminating the multi-day manual compilation that currently blocks compliance staff from higher-value analysis. CMS quality measure reporting (HEDIS, STARS, MIPS/MACRA) pulls clinical data from your EHR, applies measure calculation logic, and generates the submission file for your registry or direct CMS reporting channel. HIPAA compliance monitoring tracks Business Associate Agreement (BAA) expiry dates, logs access to PHI with the user, timestamp, and records accessed, and flags anomalous access patterns (unusual volume or off-hours access) for the Privacy Officer review queue. Meaningful Use/Promoting Interoperability attestation data assembles automatically from your EHR audit logs and patient engagement metrics. Payer-specific data submissions (quality bonus program data, utilization reports, population health measures) are generated from your EHR data on the payer's schedule and submitted via the payer's portal or secure file transfer without manual preparation. Every compliance report is timestamped, versioned, and logged -- providing the audit trail that demonstrates compliance to the reviewer who arrives without advance notice.

Automated appointment reminders, recall notifications, and follow-up communications triggered by EHR events -- reducing no-show rates by 25-40% and freeing front desk staff from manual outreach calls that consume 2-4 hours per day. Appointment reminders fire on a configurable schedule (72 hours and 24 hours before) via SMS, email, and automated voice call based on each patient's recorded communication preference; confirmation responses update the appointment status in your EHR without staff involvement. Recall notifications trigger on configurable intervals after the last visit (annual physical due, 6-month diabetic follow-up, 90-day chronic care management check-in) with direct scheduling links so patients book without calling. Lab result notifications fire when results are finalized in your EHR with a secure message directing the patient to their portal for results and instructions -- reducing inbound calls from patients asking for results. Post-visit follow-up sequences check in on patient status 48-72 hours after discharge or procedure, capture satisfaction scores, and flag responses indicating clinical concern (reported pain above threshold, side effects, unresolved symptoms) for clinical staff to call back. Prescription refill reminders fire 7 days before the last refill expires for chronic medications, reducing gaps in adherence and the associated clinical and revenue impact.