Robotic Process Automation (RPA) Use Case: Automating Claims, Eligibility, Claim Status, and Remittance Advice in Healthcare with AI Agents Supported by Public Blockchain

The healthcare revenue cycle management (RCM) process, involving claims submission, eligibility verification, claim status inquiries, and remittance advice (ERA) reconciliation, is labor-intensive and error-prone. Robotic Process Automation (RPA), enhanced by AI agents and supported by public blockchain technology, offers a transformative solution to automate and streamline these interactions between providers and payers.

Use Case Description: End-to-End Claims Automation

Scenario Overview

A hospital submits claims for reimbursement to various insurance payers. Before submission, the hospital must:

1. Verify the patient’s eligibility for coverage.

2. Submit claims with accurate information.

3. Continuously track claim statuses.

4. Process remittance advice to reconcile payments and denials.

By combining AI-powered RPA bots and a public blockchain infrastructure, this process can be automated, ensuring greater transparency, accuracy, and efficiency.

Key Components of the Solution

1. Eligibility Verification

• Challenge: Providers often face delays when verifying patient eligibility due to payer-specific systems and response times.

• RPA + AI Solution:

• AI-powered RPA bots query payers via standardized APIs or EDI (Electronic Data Interchange) for real-time eligibility verification.

• AI agents interpret responses, extract data (e.g., coverage details, copays, deductibles), and update the patient’s record in the hospital’s system.

• Public Blockchain Support:

• The blockchain maintains an immutable record of eligibility checks, including timestamps and payer responses.

• Smart contracts on the blockchain enforce that only authorized providers access this information, ensuring compliance with HIPAA.

2. Claims Submission

• Challenge: Manually entering claims into multiple payer systems increases errors and delays.

• RPA + AI Solution:

• Bots extract patient and encounter data from the hospital’s EHR system and pre-scrub claims using machine learning models trained to detect coding errors or missing information.

• After validation, bots submit claims directly to payers via secure APIs or clearinghouses.

• Public Blockchain Support:

• Claims are registered on the blockchain with cryptographic hashes, creating a tamper-proof record of submission.

• Providers and payers can use these records to resolve disputes or verify submission history.