The future of claims processing
To unlock the future of claims processing, you must lay the foundation by digitising your claims data at a point of submission, something we explore deeper in Digitising your Claims Data: Unlocking the future of Claims Automation.
Beyond Extraction: Intelligent Automation with Agentic AI
With confident and accurate digitising and data extraction as the foundation, the next frontier is automating the more complex aspects of the claims process with Agentic AI.
At Mantel, we’re actively exploring the potential of Agentic AI, the next evolution of AI systems, to address traditionally challenging areas within the claims workflow that typically require human intervention.
While Generative AI excels at content creation, Agentic AI possesses the ability to reason, plan, and execute actions to achieve specific goals. This makes claims automation an ideal application for this rapidly advancing technology.
For a deeper understanding of this transformative technology, explore our 10 Agentic AI Insights for Leaders.
Identifying High-Impact Use Cases: Intelligent Information Retrieval
For Australian Health funds the average cost of processing manual health claims ranges from $2 – $30 due to multiple departments and external suppliers being involved in the assessment process.
With an upward trend of manual claims due to providers asking for upfront payments, no POS or incompatible POS and resulting in an increase in operation costs of processing claims and a strain on call centres, there is an opportunity to reduce the increasing business cost and improve user experience.
To pinpoint where an Agent could deliver the most significant impact, we focused on a low-risk, high-reward opportunity: validating and retrieving missing information. We understand that incomplete claims are a major source of delays and rework. For our clients, 8-30% of claims fail straight-through processing due to missing information. This led us to ask:
How might we build an Agent that identifies and retrieves missing information, in order to increase Straight Through Processing?
The Future of Claims Automation: A Fully Integrated Workflow
This technology extends automation far beyond the initial member experience, creating a truly end-to-end efficient claims process:
Building upon the digitization of claims data via Optical Character Recognition (OCR), the process advances into an intelligent, Agentic workflow. This sophisticated system orchestrates various specialised agents under the guidance of a Manager agent.
The Validation Agent first evaluates the digitized receipts to confirm their validity and identify essential claim data.
Subsequently, the Missing Information Agent proactively searches for any missing details, such as business ABNs, pharmaceutical names, or claim codes, drawing from online public sources. If retrieval is not possible, this status is relayed to the Manager agent, enabling the Interaction Agent to take appropriate next steps.
Finally, the Interaction Agent automates communication with the customer, providing updates on claim status, missing information, or successful processing, ensuring a seamless and informed experience.
Agentic Claims Workflow
Further enhancements to the workflow, such as fraud detection and claims eligibility assessment, are under consideration. However, these functionalities present inherent complexities and require a thorough examination of both the criteria and ethical considerations involved before implementation.
Under the Hood: Our Technology Stack
Code frameworks used:
- Streamlit – Frontend
- Smolagents – Backend
- AWS Bedrock East-2 anthropic.claude-3-5-sonnet-20240620-v1:0
- Log streaming, message persistence – Integration
The benefits of transforming your claims process
Mantel is at the forefront of leveraging cutting-edge AI technologies to transform claims automation for Australian health insurers. By combining advanced OCR with the intelligent capabilities of Agentic AI, your business will be empowered to:
- Significantly enhance member satisfaction through a faster, simpler, and more intuitive claims experience.
- Dramatically improve operational efficiency by reducing manual processing, errors, and rework.
- Achieve higher rates of Straight-Through Processing (STP), freeing up valuable resources.
- Reduce significant operational costs associated with manual claims handling that are projected to increase.
- Future-proof your claims operations with innovative and scalable AI-powered solutions.
