Faster claims processing and process automation

Care1st Health Plan Arizona, a Phoenix-based payer who provides healthcare coverage to beneficiaries of the Arizona Health Care Cost Containment System (AHCCCS) sought ways to improve how they imported data into their core system. A recent expansion into Pima County from Maricopa County took Care1st from an enrollment of roughly 50,000 to over 70,000 individuals virtually overnight. Line-of-business records, provider panels, and other records had to be added or updated quickly to ensure continuity of coverage and reimburse providers.

Additionally, as a newly-named Third Party Administrator (TPA) for Arizona’s insurance cooperative offered through the new National Health Insurance Marketplace (part of the 2010 Patient Protection and Affordable Care Act, or PPACA), the organization was preparing to handle potentially thousands of new enrollees and provider records over the coming months. In order to expedite this data entry, and reduce the need for frustrating macros, Care1st Health Plan Arizona turned to Nintex RPA to automate the process.

Care1st Health Plan Arizona
Health & Life Sciences
Capabilities Used
Robotic Process Automation

Who they are

Based in Phoenix, Arizona, Care1st Health Plan Arizona provides healthcare coverage to over 70,000 beneficiaries.

What they needed

The organization sought reliable ways to improve how they imported and updated providers record and data into their core system.

How they did it

Care1st Health Plan Arizona adopted Nintex RPA to reduce inefficiencies and increase productivity. They were able to automatically update more than 43,000 provider records, significantly increase time efficiency processing claims, and increase data process accuracy.

The challenge

The expansion by Care1st Health Plan Arizona into Pima County brought with it the prospect of adding data on Pima County’s health care providers across each of their lines of business. Panel sizes (the maximum number of patients a provider could serve in a given timeframe), eligibility information, fee schedules, primary care physician designations, and more, had to be added or verified for every new provider they covered to ensure future claims would be paid.

The demand from new Marketplace enrollees meant thousands of individuals would be added, and tens of thousands of provider records would be updated by the end of the first quarter. In addition, the payer had a mountain of data to maintain and tasks to execute, such as reprocessing claims, approving claims, and updating NDC codes.

The organization traditionally has employed up to 15 different macros per day to perform large data entry and maintenance tasks like this, but they were unreliable. “Our macros would stop and start at random. We needed someone to sit and watch the macros to restart them once they broke. It was inefficient.” said Ivy Boyer, Manager of Business Application Systems at Care1st Health Plan Arizona.

Care1st would often turn to their small provider data management team to manually enter smaller jobs of fewer than 200 records. This meant pulling these individuals away from their daily work of maintaining the provider network and addressing claims backflow to complete the data entry.

The Nintex RPA solution

After a thorough search, Care1st Health Plan Arizona selected Nintex RPA software to replace their inefficient macros and automatically execute multiple data-related tasks.

“Normally, it would take us an hour or more to process 1,000 records with a macro. Foxtrot does it in a few minutes with no babysitting,” explained Boyer.

Boyer and her team were up and running quickly, automating routine tasks even before the three-hour basic training that was included with their investment. Nintex RPA’s Smart Scripting technology makes it easy for anyone to write and execute scripts in the presentation layer of almost any application.

Among Boyer’s recent wins with Nintex RPA:

  • Marketplace provider data: More than 43,000 provider records have been updated automatically, without macros or manual entry.
  • Updating physician panel sizes: A task that took between and 8 and 10 hours with a macro is now done in 1 hour.
  • Reprocessing claims: Macros were able to process 5,000 claims at a rate of 5 per minute across 4 sessions. With Nintex RPA, each claim is processed in seconds with total accuracy.
  • Approving claims: Nintex RPA now automatically approves up to 20 claims per minute, versus 3 claims per minute with a macro.
  • Updating NDC codes: Previously handled manually or with clunky macros, Nintex RPA recently added 1,100 NDC codes in just 1 minute for Care1st Health Plan Arizona.

Care1st Health Plan Arizona and Boyer continue to find new ways to employ Nintex RPA in their operation.

In doing so, they’re introducing new efficiencies and opportunities for productivity along the way. “Part of my job includes finding new ways to help our company increase efficiencies and reach our business goals,” said Boyer. “We’ve already been able to automate a number of tasks and do that. But, we’ve only scratched the surface of what Nintex RPA can do. I’m excited to see where we can take the technology from here.”

Part of my job includes finding new ways to help our company increase efficiencies and reach our business goals. We’ve already been able to automate a number of tasks and do that. But we’ve only scratched the surface of what Nintex RPA can do. I’m excited to see where we can take the technology from here.
Ivy Boyer, Manager of Business Application Systems, Care1st Health Plan of Arizona
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