Microsoft Scenario Library Healthcare Payor – Manage appeals

Available with: Microsoft 365 Copilot and Copilot Studio

Healthcare scenario: Payor – Manage appeals

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Scenario

Provide faster service that is easier for member to understand

1. Get requested appeal context

Use a Copilot agent to analyze requested appeal documents, medical records, and supporting documents such as clinical guidelines and policy terms.

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Copilot Studio Agent

Benefit: Saves time for the appeal and grievances (A&G) Analyst and ensures critical information is easily accessible.

Use a Copilot agent to summarize lengthy documents (analyzed in step 1) to create comprehensive case summaries, highlighting key points for review.

Copilot Studio icon

Copilot Studio Agent

Benefit:  Assists A&G Analysts in understanding the case by providing relevant insights.

Use Copilot Pages to generate a note to the A&G Analyst(s) outlining the summarized information. A&G Analysts can review/ refine the summary and add their insights and updates.

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Microsoft 365 Copilot Chat2

Benefit: Enhances clarity and comprehension about the appeals, reduces time, leading to more accurate resolutions.

Use a Copilot agent to analyze similar past cases, clinical guidelines, and policy terms to assist in decision-making.

Copilot Studio icon

Copilot Studio Agent

Benefit: Reduces the probability of human error by A&G Analysts by leveraging these insights.

Use a Copilot agent to generate resolution suggestions and provide a ranked list of suggestions with supporting rationale for each option with A&G team for comprehensive review.

Copilot Studio icon

Copilot Studio Agent

Benefit: Assist the A&G Analysts in consistent and accurate decision making.

Use Copilot Pages to maintain a durable record of all discussions, decisions, and supporting documents, which can be easily referenced in future appeals or audits.

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Microsoft 365 Copilot Chat2

Benefit: Saves time creating documentation.

KPIs

Opportunity to impact key functional area KPIs

How Microsoft Copilot can help improve product time to market

The time spent on drug research and trials. Reducing time to market can reduce costs and accelerate revenues.
Boost productivity
  • Rapidly find information
  • Diagnose problems faster
  • Check for similar issues and resolutions
  • Quickly send follow-up communications

How Copilot can help to reduce claims processing time

This KPI measures the average time to process a claim and can impact patient satisfaction.
Respond to a claim
  • Create richer, faster responses to claims
  • Have Copilot assist with drafting and summarizing emails
  • Simplify finding information for claims responses

How Copilot can help to reduce wait times

This measures the average time a patient waits before receiving care. It’s calculated by dividing the total wait time by the number of patients.
Reduce waiting
  • Address more queries in less time
  • Personalize solutions
  • Improve staff availability based on automated capacity-based scheduling
  • Diagnose problems faster

How Copilot can help to reduce readmission rates

This measures the percentage of patients who are readmitted to the hospital within a specific time frame after being discharged.
Reduce churn
  • Address more queries in less time
  • Personalize solutions
  • Improve staff availability based on automated capacity-based scheduling
  • Diagnose problems faster

How can Copilot improve patient retention

This KPI measures the percentage of patients who return to the same healthcare facility for future care.
Reduce churn
  • Address more queries in less time
  • Personalize solutions
  • Improve staff availability based on automated capacity-based scheduling
  • Diagnose problems faster

The content in this example scenario is for demonstration purposes only. You should evaluate how Copilot aligns with your organization’s business processes, regulatory requirements, and responsible AI principles.