Power Cleaning Claims Operations With enGen’s Automation and AI Tools
When healthcare claims stall due to confusing or incomplete data, members and providers are left in limbo. enGen’s award-winning AI-powered Claims Examiner tool helps payers move faster – streamlining approvals, minimizing delays, and unlocking measurable cost savings.
“Manual and messy healthcare operations are ripe for strategic retooling using automations and AI,” said enGen Chief Operating Office Matt Rhenish.
"We're using AI to get to yes faster."
When claims are flagged on the payer side with suspension or denial codes, additional reviews are triggered that take extra time and attention. Enter enGen. Our automation tool removes some of the tedious and detailed manual reviews that clog up claims examinations, making the approval process run more fluidly for staff, providers, and members.
As an always-evolving healthtech company, we’re using operations expertise and AI-assisted automation tools to break through common healthcare processing snags. The benefits of enGen’s innovations in claims processing are clear.
Points of Success
- Reducing human review time for claims approvals translates to $1.07M a year in time and related cost savings for our payer client.
- Achieving accuracy rates up to 99.64% and consistent claims processing puts payers in a strong position for regulatory audits.
- Decision support and task automations achieve faster resolution of 2.19M claims suspensions, with humans still handling denials.
- Clearing up claims confusion and approval delays leads to improved provider and member experiences.
Payer Industry Challenge
Missing and confusing data can waylay a health insurance claim while it winds through adjudication channels. The steps needed to resolve the claim can delay reimbursement and take a toll on claims staff, providers, and members.
One of enGen’s clients—a large Blue Cross Blue Shield health insurance payer—needed help with the problem.
A 2024 McKinsey & Co. survey of healthcare leaders found that 75% were looking for GenAI to improve administrative efficiency, and 55% were eyeing ways to use AI to improve IT or infrastructure.
enGen’s Solution
Customized to solve these types of problems, our AI Claims Examiner tool blends human expertise with predictive models. Powered by enGen’s AI Cognitive Engine (ACE), Claims Examiner resolves claims suspensions quickly, accurately, and with fewer human interventions to get to an approval.
The cloud-based tool reduces payers’ financial burden by cutting down staff time spent on manual corrections and on requests for more information from members and providers. The result is a faster, smoother, more hands-off approval process.
During testing with our payer client, results showed that Claims Examiner jumped on flagged claims and resolved some common suspension codes with approvals in seconds. Reducing delays and avoiding potential denials, the tool was able to resolve and approve claims without human review. Based on proven efficiencies, enGen’s AI-assisted processes could save our client more than $1M in annual operating costs.
“Our success using the Claims Examiner tool to speed approvals gives us a clear view into further possibilities for optimizing healthcare operations,” Rhenish said.
Finding the friction: How we uncovered challenges in the auth process
After analyzing data, reviewing provider feedback, and sifting through patient surveys, we discovered a decent amount of friction holding back the authorization process. For patients, providers, and health plans, an inefficient auth process means:
• Delays in care delivery: Authorizations that get caught in the system translate into poor patient experiences and unrealized care. It also leads to higher costs for payers and unpredictable revenue cycles for providers.
• Unnecessary administrative costs: Manual tasks, duplicated efforts, and communication breakdowns cause significant drops in efficiency. Providers are taken away from what matters and health plans get bogged down in a backlog of tasks.
• Inaccurate criteria: Without a consistent auth process, patient data can come from many sources. Outdated or misrepresented criteria can lead to faulty cost assessments, wrong diagnoses, and higher admin costs.
•Convoluted communications: Patients, providers, and administrators all need to be on the same page for effective care delivery. Without a reliable communication process, there can be too many channels to monitor. Faxes, mail, and phone calls to name a few.
•Ever-evolving regulations: An inconsistent, manual auth process poses many regulatory challenges when it comes to compliance. Without a streamlined digital footprint, keeping up with regulatory changes, compliance standards, and audit timelines is virtually impossible.
For many in the industry, these challenges aren’t exactly surprising. According to McKinsey, “...clinical staff must devote considerable time to reviewing [authorization] requests. Meanwhile, doctors and staff report spending 13 hours per week on [authorizations]; many clinicians believe it undermines their clinical judgment and can inhibit timely care.”
“Our success using the Claims Examiner tool to speed approvals gives us a clear view into further possibilities for optimizing healthcare operations,” Rhenish said.
Quantifying the Results
When we piloted Claims Examiner with our client, the tool yielded highly accurate results. We developed our claims adjudication tool using historical data from our Payer Platform and predictive business rules tailored to each use case.
The first use cases dealt with unclear member and provider identifications. We gradually tested automation models for specific suspension codes in the background and shadow validated the results. Shadow validation involved comparing automated recommendations with live human decisions.
During the pilot, the tool automatically tracked down related data, analyzed historical patterns, made predictions, and then sent recommendations to human claims examiners. The automated advice also indicated the level of confidence in the solution.
With those automated recommendations, claims staff resolved suspensions 50% faster.
For the first model tested, Claims Examiner matched members to claims with 99.64% overall accuracy. Early in the pilot, reviews showed the tool and the human claims examiner agreed 97% of the time. When reviewing the other 3%, data analysts found that enGen’s tool was more accurate than the human 90% of the time.
With feedback from shadow validation, enGen went a step further in training Claims Examiner to fix member-matching suspensions. Eventually, member-matching moved to full automation for approvals in instances when the confidence level for accuracy was high. Human examiners still review all claims before issuing a denial.
Careful risk assessment was a given.
Like enGen, our client is committed to responsible use of AI. Our solution keeps a human involved and only automates with AI when no adverse determination would affect members or providers.
“With regulatory compliance vital to healthcare operations, enGen deploys critical safeguards when developing our healthtech innovations,” said Christopher Atkinson, Senior Vice President of Payer Solutions.
Further Advancements
Moving beyond this early success, enGen expanded to resolving suspension codes related to National Provider Identifiers (NPIs) and other claims adjudication challenges.
When a provider has multiple NPIs and they’re triggering suspensions, ACE can clear up the confusion and speed the approval. Using AI models and tailored automations, Claims Examiner is reducing the time and manual effort involved with NPI cleanup.
During shadow validation of the NPI models, ACE has continued learning from human examiners’ approvals and denials. And it goes both ways. After reviewing instances when the enGen tool was more accurate, managers have updated their claims examiner training to fine-tune staff decision-making.
For our client, deeper payoffs will come when multiple new AI automations free up examiners to focus more attention on high-value tasks.
“Using enGen’s tools to automatically resolve procedural or data input glitches, our client’s claims examiners can use their brainpower to resolve more nuanced problems,” Atkinson said.
The process revolves around dependable results. “With our advanced solution, we build trust with our clients that claims will be processed logically and accurately,” Atkinson said. “Our clients build trust with their members and providers that claims processing will be accurate, reliable, and hassle-free.”
Broader Use of AI
Going forward, enGen is rolling out these innovations to other clients and gathering further feedback.
“A structured, phased approach minimizes risks and promotes scalable AI growth,” said Tej Daruwalla, Vice President, Enterprise Data Platform at enGen. Daruwalla heads up enGen’s AI Foundry, which sets long-term AI policy and oversees pilot projects.
Claims Examiner is part of a broader enGen effort to digitize the core of our payvider operations. And with the ACE project, enGen will stretch beyond claims to automate other processing functions, using AI when appropriate.
“The benefits will permeate healthcare operations,” Rhenish said.
The expansion could yield more cost savings for our client on top of projected savings from the ACE pilot. “With enGen’s AI tools and operational expertise, our clients can clear out their financial drains and optimize the flow of their business,” Rhenish said.
“With enGen’s AI tools and operational expertise, our clients can clear out their financial drains and optimize the flow of their business.”
Looking for ROI
enGen’s investment in innovative business processing using AI has many potential payoffs.
In the McKinsey survey on GenAI in healthcare, 64% of healthcare leaders reported a positive return on investment when they revamped their business using GenAI solutions.
“Dollars aren’t the only way to tally the ROI from our AI tools. Clients will also see a strategic payoff by putting more power and knowledge in human hands,” Rhenish said.
The Claims Examiner pilot has proven that enGen’s AI-driven processes can save adjudication time and hassles, which can lower staffing expenses and allow time for more intellectually demanding tasks. The streamlined processes also have the downstream effects of avoiding approval delays for providers and members.
As a powerful tool in a claims examiner’s toolbox, ACE supports the human element of the claim processing journey. The automated assistance improves examiners’ speed and accuracy, minimizes errors, and strengthens consistent decision-making.
“Using our AI Cognitive Engine, we’re transforming the business side of healthcare, enhancing efficiency, accuracy, and cost-effectiveness,” Rhenish said.
How Can enGen Help You?
Our commitment to strategic innovation makes enGen a key partner for payers navigating a complex regulatory landscape and searching for highly efficient and compliant solutions. enGen’s AI program focuses on ethical and transparent solutions, ensuring peace of mind for payers, providers, and members. More than a technology partner, enGen is committed to building a future where technology empowers human expertise to support healthier lives for all.