Increasing productivity using a claims copilot
Today, health claims are processed manually by claims adjudicators. Adjudicators manually open claim documents that include the discharge summary, laboratory reports and medical bills (available in the form of pdfs, images). This process is time consuming as it involves looking at 20+ pages, applying policy terms and conditions, assessing whether the correct treatment has been followed for the diagnosis and eliminating fraud, waste and abuse.
ICICI Lombard leveraged Microsoft Azure OCR / Computer Vision, Microsoft Azure OpenAI and Microsoft Azure AI Document Intelligence to create a claims co-pilot to help increase claims adjudicator productivity
Enabling claims adjudicators
A claims Copilot was developed for claims adjudicators to provide a comprehensive summary of health claims from submitted documents. The solution consolidates information, including diagnosis, treatment provided by the hospital, and compares it with both NHA (National Health Authority) and disease treatment guidelines using OpenAI. This system combines Azure OCR, Azure AI Document Intelligence, Azure OpenAI, and an indigenous model to structure data from claims documents into categories such as diagnosis, clinical presentation, medical history, treatment, and lab investigation reports.
Azure OpenAI helps identify diagnoses from discharge documents and summarize typical treatments for those diagnoses, which are then compared to NHA guidelines to check the hospital’s adherence to the treatment protocols.
This solution has reduced the time for claims adjudicators to process a single health claim by over 50%. Additionally, the use of NHA and OpenAI guidelines ensures consistent adjudication, eliminating person-dependent variability in manual processes. Over time, this solution should help in reducing fraud, waste and abuse providing additional monetary benefit in terms of claims ratio
Sanjeev Mantri
MD & CEO
Microsoft’s OpenAI models are assisting ICICI Lombard in enhanced understanding and assessment of risk, streamlining claims processing, and in improving customer service. Our partnership with Microsoft has helped us leverage and gain valuable insights, expedited decision-making, and we continue to position ourselves at the forefront of technological innovation that benefits our customers, employees and all other stakeholders.
Over
2x
productivity increase of claims adjudicators
ICICI Lombard, India’s leading private general insurance company offers a comprehensive and well-diversified range of insurance products.
More details at https://www.icicilombard.com
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