©Copyright 2015 OpenConnect Systems Inc.

Insurance Claims Auto-Adjudication

SolutionThe WorkiQ Automation solution provides the actionable in-telligence, and the tools to quickly improve operational first pass rates (OFPR). The WorkiQ Automation solution follows a simple approach:• WorkiQ Workforce Analytics provides analysis of applica-

tions and claims metrics used by manual claims examin-ers.

• WorkiQ Workforce Analytics provides the data needed to identify and understand high-value automation op-portunities.

• WorkiQ Automation robots rapidly queue inventory, ap-ply shared-learning to auto-adjudicate complex claims, and dramatically increase first pass rates.

BenefitsThe WorkiQ Automation solution provides actionable intel-ligence to quickly automate high-impact edits and lower the cost of manual claims adjudication.

WorkiQ Automation results in:• Lower total cost per claim• Reduced processor FTE• Reduced adjustments• Improved Time of Service

The WorkiQ Automation solution delivers quantifiable re-sults, rapidly improves claims operations, and delivers ROI within one year of deployment.

Solution Brief - WorkiQ Process Automation

Manual adjudication creates several issues:• Elevated claims processing cost• Lower quality & consistency• Increased service time & inventory backlog

Improved first pass rate requires:• Inspection of why primary platforms suspend claims• Analysis of the manual workflows used to resolve sus-

pend claims• Software robots that utilize the logic and processes of

your best claims examiners to increase auto-adjudication

ChallengeClaims adjudication platforms can apply pre-scripted business logic, follow repeatable patterns, and automatically process standard claims. However, when exceptions occur, or external data is necessary, most claims systems do not have the intel-ligence to act as virtual users and seek out resolutions. As a result, complex or irregular claims require manual adjudication.

Example: Fully Automated Claims Auto-Adjudication

©Copyright 2015 OpenConnect Systems Inc.

OpenConnect Systems Inc.2711 LBJ FWY, Suite 700Dallas, Texas 75234

AboutThe WorkiQ® solutions drive produc-tivity improvements throughout your workforce. WorkiQ® provides visibility across the organization of what, how much, and how effective employees

complete their work. Only WorkiQ® pro-vides the visibility to know exactly what work is being done, how it is actually being done, and the quantitative mea-sures required to improve workforce productivity.

Solution Brief - Process Automation

(972) 888-0407

www.workiq.com

@MyWorkiQ

Customer SuccessCustomer #1—Midwestern Regional Plan

Customer #2—Eastern Regional Plan

Customer #3—National Plan

Profile• Not-for-profit plan operating at 82% operational first

pass rate (OFPR)• Hundreds of suspend codes and changing business con-

ditions stalled first pass rate improvement

Results• Finalized ~200,000 claims in first year of deployment• Improved OFPR to 94.4%• Yielded a total annual savings of $6 Million

Profile• Not-for-profit plan operating at 77% OFPR• No prior experience with automating claims external to

claims engine

Results• 155,000 claims finalized within first six months• Improved OFPR to 82% in first year• Yielding a total annual savings of $3 Million

Profile• For profit plan operating at 74% OFPR• Had existing program of automation with 75+ robots in

operation• Multiple disparate processing centers and lines of busi-

ness created automation challenges

Results• Automated 50,000 claims within first 6 months• Improved effectiveness and lowered cost of automation• Savings of $3 Million in first year

Automation Components

Mainframe

Web Services

Database

Desktop

IntegrationsCentral Administration

Business Rules

Platform ServicesOrchestration & Deployment

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