Problem Statement

Nected_Solution_Section_Begin

A medical billing and revenue cycle management (RCM) services company dedicated to optimizing billing processes for healthcare providers faced significant challenges in processing insurance claims efficiently. Their operations involved:

1. Manual Claim Processing: A team of approximately 500 operations staff manually processed claims, which was time-consuming and prone to errors.
2. Complex Claim Conditions: Handling 600-700 claim conditions based on patients' histories and various parameters made the process intricate and overwhelming.
3. Inefficient Workflows: Lack of automation led to delays, increased operational costs, and inconsistent decision-making.
4. Data Security Concerns: Processing sensitive patient information required strict compliance with healthcare regulations and data protection standards.

These challenges resulted in:

1. Extended Processing Times: Manual workflows led to delays in claim approvals, affecting cash flow for healthcare providers.
2. High Operational Costs: Maintaining a large team for manual processing significantly increased overhead expenses.
3. Inconsistent Outcomes: Human error and variability led to inconsistent claim approvals, impacting customer satisfaction.
4. Risk of Non-Compliance: Without secure and compliant systems, there was a heightened risk of data breaches and regulatory penalties.

Nected_Solution_Section_End

Solution

Nected_Solution_Section_Begin

The company partnered with Nected to transform its claim processing operations using Nected's low-code/no-code rule engine and workflow automation platform. This collaboration led to:

1. ‍Seamless Data Integration with PostgreSQL:
   Within just 20 minutes, the team connected their PostgreSQL database to Nected’s self-hosted solution, pulling in patient data, billing codes, and insurance details. This rapid integration ensured all claim-related information—from ICD and CPT codes to coverage rules—was readily accessible for automated decision-making.‍
2. Advanced Decision Tables and Workflow Automation:
   By configuring over 600 rule conditions in Nected’s Decision Table feature, the company encoded intricate clinical billing logic, payer-specific guidelines, and regulatory compliance checks with no coding required. Complex workflows were set up to automatically route claims for:‍‍
   This eliminated the reliance on a large operational team and minimized human error.‍
3. Real-Time and Scheduled Processing:
   Nected’s Workflow Automation enabled both immediate and periodic claim evaluations. Urgent claims received instant decisions, while scheduled batch runs ensured timely completion of routine reviews. This hybrid approach improved responsiveness and optimized resource usage.‍
4. Enhanced Security and Compliance:
   Deployed on a self-hosted infrastructure, Nected maintained full HIPAA compliance and safeguarded sensitive patient data. Robust audit trails, role-based access, and end-to-end encryption ensured regulatory adherence without compromising processing speed.

By leveraging Nected's platform, the company not only streamlined its claim processing but also positioned itself to scale efficiently while maintaining compliance and improving service quality.

Nected_Solution_Section_End