Reason and Benefits of Considering RPA for Claims Appealing

 Erika Regulsky RCM, RPA
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Introduction Claim Denials and Underpayments

Claim denials and underpayments are the main areas of defects in the revenue cycle that indicate a provider’s inability to comply with payer requirements or a payer’s inability to accurately pay a claim,  service, or procedure. The next step in resolving these issues is to appeal the claim using supporting documentation and records. These processes can be simplified using robotic process automation and these RPA bots can assist in resolving these repetitive manual paperwork process burnouts. 

Underpaid claim

The main burden when it comes to filling out paperwork is the entire repetitive process. Staff can be overworked or burnt out due to the huge volume of these tasks. Moreover, the quality of the work is also in question when it comes to filling up different payers’ appeal forms and following their format of submission. Implementing appeal robotic process automation will ease staff from manual labor. Work and concentrate on the quality of the work because the appeals are the last line of defense when it comes to denied claim reimbursement.

Why use robotic process automation for an appealing process?

We all know that creating a paperwork RPA system that can actually do the paperwork for you? As a matter of fact, it is possible using today’s RPA technology for these types of manual paperwork. To keep up with the narrow time limits of these payers’ appealing process it is important to submit these records as soon as possible because if timely filing for appeals the payers are exceeded then you will not be able to pay this claim or service after the timely filing limit has passed which is the exact reason why appealing robotic process automation system is required because all of these payer guidelines and documentation requirement that it takes almost 30mins to an hour to complete an appeal, what if we eliminate 55mins worth of time used to create these appeals and your staff can focus on consolidating medical records nd surgical notes instead of manually keying in the data?   

Yes! That is absolutely possible using RPA Bots for appeals; they also will automatically know which payer needs which appeals mail address or identify the designated Third Party Administrator (TPAs) or any other HMO plans for federal insurance companies. All in one appeal resolution automation according to your practice’s needs can be customized as these bots can be programmed according to the current workflow methods followed in your in-house RCM team.

Benefits of using Robotic process automation for appealing


Appeals RPA bots provide process and workflow improvement in identifying the root cause of denials and appealing underpaid and denied claims. This Robotic process automation for appeals will automatically analyze ERAs and apply rules to place suspect payments and denials in the appropriate team or individual work queues for appeal. It has the internal self learning protocol which constantly evolves to abide by your insurance companies contracting, timelines and regulations.

Comprehensive and cost friendly

The RPA bots utilize dashboards and key performance indicators (KPIs) to produce quantitative Management wherever knowledge is measured and accustomed drives improvement choices on denial trends, appealing, and underpaid claims. It uses package as a Service (SaaS) technology for easier setup while not increasing capital expense, thus allowing to re-obtain the investment for this RPA system.

Customization according to workflow and hospital type

Appeal RPA bots employ unique board views customized to your process that help visualize workflow, manage flow, make process policies explicit, and improve collaboration. It gives you the edge in the process protocols, the tool for managing the appeals process and creates a chance for the RPA bots to learn from the existing appealing methods and guidelines and gradually adapts and evolves over time by implying certain simple protocols and operational tactics. Robotic process automation appeal bots provide an annotated view of each case’s EOB to rapidly identify and interpret the reason for denial. The appeal process RPA can let your staff correct the mistakes to and eliminate any blocks which are not comparable to the current insurance disputes and hospital regulations, creating a time conscious appealing process.It identifies the problems areas in certain payer appeal processes and send notifications to the staff requesting to correct them in the workflow so that the entire medical group or hospital can streamline the process rather than waiting for errors to occur.

Use of industry standards and regulatory databases in Appeals RPA

The appeals RPA bots have inbuilt denial prevention solutions by the use of dashboards and KPIs including HFMA MAP Keys provide quantitative management where data is measured and used to drive improvement decisions. Trending analysis feeds continuous improvement efforts. Additionally, reports are generated as multi-tabbed Microsoft Excel documents to provide full visibility of this critical segment of the revenue cycle. Appeals robotic process automation is directly linked to a database that provides a repository of knowledge to assist your denial management team in taking control of the appeals process. The database can be available across all involved departments to assure organizational accountability.

How does RPA assisted claims appeal work?

RPA appeal

Robotic process automation appealing helps increase productivity by standardizing processes and providing explicit instructions for each step in reviewing, fixing, and/or appealing a denial. 

  • Information and claim data is naturally extricated from ERAs into case records which can auto-populate fields in complex insurance appeal forms creating preset patient encounter and service level information automatically entered into these fillable PDFs
  • Similar information can be converged into claim letter formats utilizing Microsoft Word or other .docx word processors, which brings about maximum reduction of time spent on manual entries and decrease of records and transcription errors.
  • RPA bots for appealing also provide an interface to manage automated or manual assignment of appeals to third parties with relevant expertise.

Other Significantly important process performed by RPA appeals


Your remittance 835 data and claim information is a resource that just turns out to be more significant as it helps you measure and deal with the achievement of your business objectives. Robotic process automation appeal bots examine and report your advancement against the important HFMA MAP Keys and other KPIs. All the more significantly, it gives automatic underlying denial investigation to help distinguish and quantify your advancement against the main denial trends prevention goals.

Contract Variance

Another key function of RPA-assisted appealing is contract variance reporting. Our RPA bots import 835 electronic remittance files and measure payment accuracy against fee-for-service payer contracts. From that point, Robotic process automation assisted appealing bots provide variance reporting vs. the fee schedule, automating the completion of various payer dispute forms and letters, providing completed denials management, and tracking and managing the appeals workflow processes


We understand that cost of billing is higher than usual and costs for appealing are higher than that, mailing and postal charges including manual copies for insurance which do not accept faxed or emailed appeals Implementation of robotic process automation for most of these tasks will reduce costs significantly for your hospital or medical group, many CEOs and CFOs think creating custom made automation systems are expensive, but as we discussed earlier your healthcare organizations return of investment using RPA assisted appealing bots is clearly hinger that utilizing manual workforce for such a repetitive process. 

Appealing RPA bots update themselves every week and keep their database fresh in relation to the insurance guidelines,  formats, and appealing time limits,  we can prevent thousands of dollars from being written off as not collectible claims which can be appealed and gotten reimbursed. BillingParadise has created such custom-made RPA systems to ease the practice burden of handling manual paperwork tasks. Find out the areas in which your hospital or medical group requires automation and talk to our experts to learn more on how to. Simplify these processes through Robotic process automation.

 Appointment Scheduling using Robotic Process Automation

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I’m a multi-certified revenue cycle management professional and compliance officer with 20+ years of experience. I contribute articles to leading healthcare publications and journals. I am currently working as Senior Transition Manager, in BillingParadise headquartered at Diamond Bar, California. BillingParadise offers Medical Billing Services that intersect perfectly with the EMR/Practice management system you use.BillingParadise has offices in New Jersey, New York, Florida, Georgia, Minnesota, and Texas.

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