When Medicare claims are denied, the The Centers for Medicare & Medicaid Services (CMS) provides a formal process to beneficiaries for appealing those claims. It’s a heavily utilized, five-step process wherein QICs (qualified independent contractors) review claim data and make recommendations via decision letters. For the last five years, Maximus has employed Robotic Process Automation (RPA) at several critical junctures during the review and appeal process, assisting in the more than 300,000 reviews our team conducts each year.

For example, we use RPA for data entry, case assignment, and to ensure that acknowledgement letters are stored accurately and efficiently in our systems, as well as in CMS’s. Previously, this data entry was performed by a staff member who can now perform more complex support for the program. We’ve also developed and deployed our own proprietary enterprise RPA tool to retrieve data from more than 20 entry points in our systems. This enables us to quickly and more accurately generate decision letters, using RPA to determine what data goes in which fields of the letters.

As a result of our strategic adoption of RPA throughout the entire review workflow, we’ve saved countless man-hours and client resources, and we’ve driven better quality in the process. Our client is happy with the results and our staff is more engaged on the project.