Straight Through Processing in private health insurance companies



When, at the end of the 90s some private health insurance companies switched their incoming mail from paper to a document management system (DMS), it was already a revolution.

Optical Character Recognition (OCR) then ensured that text could be recognized and captured from scanned documents. The electronic Intelligent Character Recognition (ICR) then made it possible not only to classify the document type but also to capture the content. Supporting plausibilities work with every Input Management, which simplifies the manual re-entry of documents and raises the recognition rate even higher. In addition, a service hub can be used to a certain degree with additionally connected partner companies, i.e. an interface for the direct import of invoice data, for example, from settlement agents.

The term "Straight Through Processing” " then became synonymous with the possibility of automated benefit billing and has even become a German Wikipedia entry. This at least shows its increased relevance. The typical tasks are presented and the advantages are briefly described here: The advantages of straight through processing are the reduction of processing time and the increase of processing quality for standardized operations that do not require user interaction. You learn relatively little about progress or future prospects here. However, it is precisely this information that is promising for further development. This is because potentially positive further effects on service, a higher quality of work, improved cost structures and better back offices for sales throughout an insurance operation would also be interesting.

Much has evolved since then and the detection rates of software vendors have improved. Downstream calculation components or entire benefits systems in the benefits process can work with the collected data. This was a big step closer to automated processing, that is, the idea of straight through processing benefit claims. Some insurance companies are already very advanced in this respect and work with the recorded data to process benefits.

The benefit management software in|sure Health Claims can be accessed with the data collected. It is designed to process the benefit calculation as automatically as possible. For the standards, in|sure Health Claims will take over bulk processing to improve turnaround times and create more time for individual processing. For the remaining benefits operations, employees should concentrate on those that require complex processing.

There is still more potential on the backend!

In terms of the digital future of insurance, a lot has happened on the front end, but still the back end remains the key to modernization. When linking in|sure Health Claims to the insurance company's peripheral systems, the project teams are also regularly confronted with the Input Management and Benefits departments. In speaking with insurance companies that are already using OCR/ICR or have recently implemented it, you get the impression that transaction backlogs are constant. This is explained by a lack of experience, the low quality of data collection and the financial risk of possible incorrect calculations and payment of benefits.

Is the idea of Straight Through Processing alive?

The potential of straight through processing has not yet been exploited in terms of feasible quality! The organizational structures in most companies provide for separate departments with Input Management and Benefits departments. This means that uniform responsibility does not always exist. Confidence in recording quality is often not consistently defined or present. Monetary incentives for staff or budgeting for quality across departments is rarely undertaken. A contact in the department from an insurance company underlined this hypothesis with the statement: "We react when an error occurs officially."

It doesn't have to stay that way, and the Six Sigma approach to quality management could provide a solution for more trust in data and the use of Straight Through Processing. The Define - Measure - Analyze - Improve - Control(DMAIC) process developed for such situations could support this.

What measures can increase Straight Through Processing?

Im At the beginning, the customers of the process and the needs to be fulfilled are defined in Define. The focus will be on the question: What prevents the increase in dark processing? The critical characteristics are derived from this. In addition, project parameters can be set to determine whether a one-time improvement project is implemented, or whether it is best to implement a permanent improvement process. Used as a quality project, this would be very beneficial as a constant companion between Input Management and the Benefits department to increase Straight Through Processing.

In the technical systems of Input Management, the data in a document is evaluated for each data field. Depending on the software, for example, a three-level classification from unsafe to safe is marked in various colors or an evaluation with quality keys is performed. These are generated per data field, for example, as follows:

  • Value not usable
  • Value not found by ICR
  • Value found reliably by ICR
  • Value found unsafe by ICR and accepted by automatic format checks
  • Value by ICR found uncertain and changed by employees

Of course, there are other manifestations. First, it must be defined which data fields are to be recorded with which logic. Then there is a value behind each quality key. This does not correspond to a recording quota as a percentage. Therefore, from the point of view of a Benefits department, the quality keys do not have a concrete comprehensible translation in most cases. There is no definition of a quality assessment, as staff would do. This must be worked out together.

In the Measure step, the project team uses various methods and instruments to determine whether the process meets the customer's quality requirements. In the subsequent Analyze phase, the causes of the problem are identified through a review of the process and data.

Input Management and the Benefits department should spend extensive time on the Define, Measure and Analyze phases. The real core of the problems must be identified. The human reflex for immediate solutions or quick wins must not be allowed to take over. These could be implemented immediately, but they prevent a quality that can be permanently implemented.

In the following Improve phase, solutions for the identified errors are sought using creativity techniques, and checked and assessed for feasibility. A common implementation of the qualitative use of data fields needs to be worked out. There needs to be a common definition by Input Management and the Benefits departments on how individual data and the sum of data per document type are qualitatively assessed.

In developing a common understanding of how the recording quality of an entire document might be assessed, there are the following possibilities:

  • Weighting by an arithmetic mean has the advantages of a configuration for all document types and a low configuration effort during operations.
  • The individual weighting of the data fields according to relevance has the advantage that individual data fields can be generally excluded from use or adjusted with practical knowledge.
Mixed forms can also be used, depending on the document type. After that, the test of the dark processing can take place in a downstream benefits system. If the data fields are complete and the quality keys are within the professionally accepted quality, then dark processing is carried out. If the quality keys in a document type are not accepted, the Straight Through Processing is terminated.

The sustainable implementation then takes place in a jointly documented standard. To this end, the measures in Control are examined on a regular basis. If deviations occur, they are corrected with defined measures. Sustained control and measurements are needed here in order to be able to gradually raise the quality of the dark processing.

Working together for greater Straight Through Processing

The common view of Input Management and the Benefits departments can be improved and set up by a jointly agreed upon process. More acceptance and more trust in process automation can create freedom for individual transaction processing and lead to faster customer service for the insured parties. Improvements in Straight Through Processing is possible together.

If you would like to know more about increasing the Straight Through Processing quota, then please don´t hesitate to contact us.

Do you have any questions or comments? Then please leave us a comment.

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