Microsoft Scenario Library Healthcare Payor – Speed claims processing

Available with: Copilot Studio/GitHub and Azure AI Foundry

Healthcare scenario: Payor – Speed claims processing

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Scenario

Provide faster service that is easier for member to understand

1. Get incoming claims context

Use a Copilot agent to cross-check provider details noted on pended claims against internal system records.

Copilot Studio icon

Copilot Studio Agent

Benefit: Saves time for claims adjudicator in understanding claims details.

Generate a report on pended claims with missing fields, discrepancies with provider match, flagged fields, along with the name of the submitting provider for each pended claim.

Copilot Studio icon

Copilot Studio Agent

Benefit:  Assists claims team in understanding claims details by providing relevant insights.

For pended claims with missing fields, flagged fields, or that contain discrepancies with provider matching, use the agent to draft a letter requesting additional and/or updated information from providers.

Copilot Studio icon

Copilot Studio Agent

Benefit: Speeds up the claims review process by providing concise, relevant information.

If the Claims team receives updated provider information, use a Copilot agent to update the provider management system.

Copilot Studio icon

Copilot Studio Agent

Benefit: Automating updates increases accuracy and reduce the time required for claims processing.

Once the claim is submitted for re-adjudication, use the Copilot agent to search and retrieve relevant policy documents to the assist re-adjudication team with decision making.

Copilot Studio icon

Copilot Studio Agent

Benefit: Provides quick access to policy documents, aiding in accurate and timely claim adjudication.

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.