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7 Essential Features of a Modern Benefits Processing Platform

September 14, 2016

Healthcare providers receive high volumes of Explanation of Benefits (EOB) documents from payer organizations. Quickly and efficiently processing the data in these documents is essential to avoiding consumer dissatisfaction and accelerating cash flows. However, many healthcare organizations continue to process such documents manually, making the process error-prone and time consuming. In fact, a key challenge is the prevalence of a high number of typing errors related to patient account number and reason code. So how can you transform existing EOB processes to avoid such errors and meet business objectives?

A modernized EOB processing automation platform is the answer. It can help you enhance service delivery to payer organizations by enabling systems validation, such as flagging of mismatched entries, and processing big batches on priority. Typically, big EOB batches (ranging from 3000 to 25000) are assigned a lower priority and processed later. Reversing this process can optmize productivity by processing a higher number of EOBs in lesser amount of time.

Incorporate seven must-have features

Here are seven key functions that your automated platform should have to drive quick and error-free EOB processing.

1. Well-defined user roles: An ideal EOB processing software should support defined roles for users     for enhanced efficiency, access and security, a capability that is typically not available in legacy     applications.

2. Automated batch download, allocation, and tracking: This will increase productivity, eliminate     wait times, and help users prioritize sensitive and critical clients.

3. Easy copy-and-paste option: Reading data from scanned images can be done using Optical     Character Recognition (OCR); however, that can be expensive. Instead, allowing users to easily     copy     patient information from the scanned EOB images into the work-in-progress files     eliminates     the need     to manually key in information, reducing cycle time and human errors.

4. MPI ratio calculator: The Master Patient Index (MPI) is the central database of customer     information. An MPI ratio calculator indicates whether the patient record matches this index,     enables     MPI analysis that helps identify patients with low MPI match rates, reduce mismatch,     and improve     data accuracy.

5. Quick keyboard shortcuts in the balancing grid: A modernized platform should support     keyboard     shortcuts in the line balancing grid such as cursor movements, and movement from     one cell in the     balancing grid to another cell using the Tab key, and so on. This can help     reduce processing time by     approximately four seconds on average, per transaction.

6. Instant detection of blank or dummy EOBs: While processing EOB batches, the processor     sometimes erroneously creates blank and dummy EOBs. A modernized platform should be     able    to detect and restrict the submission of a batch containing faulty EOBs. This will help reduce     rejections,     errors, and overall processing time.

7. Agile report generation: EOB processing automation requires day-to-day monitoring and     governance. A modernized platform should therefore support a wide range of reports: a user     summary report can provide user-wise allocation status for a particular batch, enabling efficient     allocation of work; a TAT report can provide visibility into batches pending processing, enabling     the users to prioritize batches; a check level EOB report can provide the location of an EOB with     respect to     its image number.

In a rapidly changing healthcare ecosystem, optimizing time, cost, and resource utilization are increasingly critical objectives for healthcare providers. Resorce-intensive processes can cause major setbacks, resulting in sub-optimal outcomes for all stakeholders. A modernized EOB platform can drive better quality care, higher cash flow, and superior return on investment.


Saptarshi Dhar works in Tata Consultancy Services (TCS) Business Process Services (BPS) Insurance unit. With 12 years of experience, he has worked across verticals including Manufacturing, Banking, Insurance, Information Technology, Outsourcing and Telecom. He holds a Bachelors degree in engineering from Regional Engineering College, Silchar; an Executive Post Graduate Program (PGP) from Xavier Institute of Management, Bhubaneswar; and an MBA from Symbiosis Institute of Operations Management, Nashik. He is also a certified Lean Six sigma Green Belt, Lead auditor and Supply Chain Management professional.