Leveraging automation to streamline independent dispute resolution
Key takeaways
The Centers for Medicare & Medicaid Services (CMS) uses an independent dispute resolution (IDR) process under the federal No Surprises Act (NSA) to resolve out-of-network payment disputes between insurers and care facilities. Tapped by CMS to help address time-consuming processes and accelerate case processing, Maximus streamlined the complex dispute workflow using artificial intelligence (AI) and robotic process automation (RPA) to reduce manual tasks, lower labor costs, process more cases, and significantly reduce time to resolution.
AI-Powered Independent Dispute Resolution from Maximus.
Situation
Federal efforts to reduce unexpected medical billing for consumers require compliance with NSA billing protections and an independent dispute resolution (IDR) process to evaluate cases against established NSA eligibility criteria. Through certified IDR entities like Maximus, CMS plays an important role in providing arbitration for payment disputes between providers, facilities, plans, insurers, and patients.
Challenge
CMS tasked Maximus with addressing unusually high volumes of pending cases and bottlenecks in its NSA eligibility determinations. These stemmed in part from inefficient IDR processes that required manual information gathering from multiple sources of unstructured or non-standardized documents.
Solution
Maximus delivered an RPA- and AI-powered system to streamline the IDR eligibility determination process and key IDR communications using cost-effective automation. The solution includes:
- Maximus Intelligent Document Processing using leading commercial software tools that extract and combine key data from both unstructured and structured sources to automate information gathering
- Maximus Eligibility Rules Engine leveraging flexible, easy-to-follow rules in a coded workflow to automate determinations of IDR eligibility approval, rejection, or escalation for human-assisted reviews when needed
How We Did It
While other AI-powered solutions from external vendors had proven too costly, Maximus delivered an effective and efficient solution that integrated the best technology for CMS’s mission needs for fast and impactful results. The Maximus team:
- Delivered a CMS-specific solution that takes advantage of modern AI and RPA capabilities while addressing NSA rules
- Removed repetitive, manual tasks using automated workflows for eligible IDR cases
- Streamlined the entire IDR process, including automation for key communication from welcome letters and case management to determinations, notifications, and invoices
Results
- Fully processed and eliminated a large backlog of disputes in a fraction of the time compared with previous manual IDR processes
- Improved time to resolution for IDR cases, achieving a median eligibility processing time of two business days
- Increased overall IDR workload capacity, now processing 700+ cases daily
- Significantly reduced manual workload and lowered labor costs with up to 45% of disputes resolved using automation
- Delivered scalability and efficiency with a modular and extensible AI-powered solution that can be reused for similar CMS workflows
- Improved accuracy and quality by automating case evaluation against a standardized set of rules to eliminate manual errors