Enhance member and provider experience with AI enabled automations of key processes

Smartbridge Use Case Collection

Smartbridge is empowering nonprofit, managed care healthcare organizations serving patients under the Medicaid, Medicare program like STAR, STAR + Plus, and CHIP coverage to optimize their member and provider related processes.

Use Case Overview

Smartbridge’s solution provides valuable key features for organizations looking to optimize provider and member processes. Automating enrollment, authorizations and claims with AI and advanced analytics will enable Managed Care Organizations (MCOs) to fulfill their commitments quicker, with minimal costs.

APPLICABLE CAPABILITIES:

Artificial Intelligence
Automation
  • Digitize and automate the processes related to gaining and losing members.
  • Automate prior authorization, claims, and invoice processes.
  • AI-powered analytics to detect fraud and billing inconsistencies.
  • GenAI-enabled customer feedback capture and analysis.
  • Automated Audit and Compliance Reporting.

APPLICABLE SOLUTIONS:

Microsoft Azure
Microsoft AI
Microsoft Power Platform
Microsoft Fabric

Strategic Business Goals Supported

MCO Benefits:

  • Reduce the need and dependence on temporary workforce during peak periods by 75%.
  • Improve provider experience with faster authorizations and claims.
  • Reduce time and effort on end-to-end claims processing, while also improving the accuracy.
  • Fraud detection with AI-powered analytics.

Member Benefits:

  • Improve member experience by reducing wait time for prior authorizations by 50% ultimately resulting in cost savings.
  • Improve member experience with better accuracy of records and streamlined support
  • Personalized experience with tailored coverage and care recommendations, real-time alerts and notifications

Solution Capabilities

Integration
Seamlessly integrate with CRM and Clinical Systems
Analytics
Easily extendable business rules to validate the data provided by members and providers to reduce fraud and enhance patient care
Claims Processing
Enables faster reimbursements, reduced denials, and administrative overhead
Personalization
Improve coverage and care recommendations, alerts, and notifications
Enhanced Member Experience
Ensure patients receive timely and accurate responses/approvals fostering trust and long-term relationships and increase YOY member enrollment
Enhanced Provider Experience
Reduced administrative overhead, faster reimbursement, and fewer claim denials improve overall efficiency in delivering care
Automate Member Onboarding & Offboarding
Extract the enrollment data using AI and automate the approval workflow
Automate Prior Authorizations
Use AI and automation tools to process prior authorization requests (incl handwritten) in a timely manner saving lives and improving care

75%

reduction in temporary workforce

Automating repetitive tasks reduces the need for temporary or seasonal workforce hires by 75%, which can cut costs by up to 40%.

5-10%

potential savings

Automation enhances the accuracy and integrity of claims processing by flagging discrepancies, and reducing fraud and incorrectly billed items. MCOs could potentially save up to 5-10% of their annual claims costs by preventing fraud and overpayments, as automation ensures proper checks are in place before payments are made.

20-30%

reduction in operating costs

Automation will reduce operational costs saving MCOs 20-30% in administrative costs MCOs can handle a higher volume of claims with fewer resources, lowering overhead costs.

50%

reduction in wait time

The average wait time for prior authorizations can be reduced by up to 50%.

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Smartbridge Use Case Library is a collection intended to spark ideas, inspire innovation and get you thinking about real world value.