Health Plan Automation Solution : RPA, API, BREs, which is ideal for you?

Automation has been at the forefront of technological innovation for quite some time now. Every industry needs automation in one form or another, be it Robotic process automation, industrial automation, APIs, or Business Rules Engine (BREs), it is inevitable for organizations to accomplish day-to-day tasks without leveraging automation.   

Health Plans can leverage automation by automating certain functionalities to reduce errors and speed up processing. Another use case of automation for health plans is the member engagement solution that patients/members use. Heath plans can keep track of patients’ health by sending out automated medication reminders, appointment reminders, and more.  

What Automation Solutions Should Health Plans Adopt? 

RPA in Healthcare Insurance:

Robotic Process Automation has been implemented across multiple organizations for multiple departments to automate 100s of tasks. RPA can be leveraged to do basic manual tasks such as data entry, task assignment to system monitoring, sending notifications/alerts of medication adherence and appointments to patients on their health app. 

 Benefits of RPA in Health Plan Automation: 

  1. Cost-Efficient 
  2. Turn Around Time (TAT)  
  3. Improved Customer Satisfaction (CSAT) 

Where RPA Doesn’t Shine in Health Plan automation? 

  • Intelligence and Logic Driven tasks  
  • If Manual Tasks are not done very often  


  • Health Plan Selection for a Member based on more than one thousand Parameters and is logic driven 

How Health Plans Can Leverage RPA? 

  • Claims Life Cycle Management:

    Claims  Life cycle management is one of the most used solution by payers. Every single claim that comes from the providers/ is processed via this system. Each claim should be analyzed with the utmost diligence as any errors may lead to compliance issues . RPA can alleviate this concern by automating manual tasks like claim decision notification, denial routing, etc. 

  • Member Engagement Solution:

    Every payer organization needs a robust member engagement solution. Member engagement platforms like mobile apps, portals, and medical devices are some of the ways health plans can track their members’ health and deliver quality care. RPA solutions can send medication adherence alerts, schedule appointments, monitor health progress so that, payers can provide the right care plan for the member. 

  • Provider Network Management solution:

    Every payer needs to have a provider network solution. This solution helps health plans identify, onboard, providers, contracts, etc. An RPA-infused PNM solution can help health plans eliminate manual management, contracting, profiling, etc.  


Related: RPA in Healthcare: The Areas for Automation for Health Plans [Whitepaper]

API Solution for Payer Automation:

APIs have been the backbone of interoperability for a while now. This essentially allows two different systems to talk to each other like a virtual bridge that helps with data exchange  

Why go for API 

Recent Regulations Mandates FHIR Compliant APIs for Health Plans 

  1. APIs can be adopted if your task requires minimal automation 
  2. Legacy Systems are known to be isolated from other systems in the environment. An API can fix that for you. 

Where do APIs fail in Health Plan Automation: 

  1. APIs are not the solution if you require a huge volume of manual tasks that need automating   
  2. APIs are not the solution if your problems require logical decision making  
  3. APIs are not a good idea if your software system has weak security  


  • Automated Alerts for Member Engagement Apps,  
  • Denial Routing and Claims Assignment and verification,  
  • Mock Audits to avoid regulatory compliance 

Where Health Plans Require APIs:  

The recent cures act regulations ask payers to implement these APIs:   

  • APIs for patient access of reports:

    CMS has asked health plans to add FHIR APIs to their member engagement system so patients can get their information without a hitch.  

  • APIs for provider directory :

    Health plans must update their website with the latest provider information which require FHIR APIs to be built into their system.  

  • APIs for Provider access:

    APIs need to be built by payers so that patient and claims data, etc can be exchanged with the providers with ease and help speed up payments and discharge.   

  • APIs for Payer to Payer:

    CMS has asked health plans to implement APIs to share patient data between old and new payers if and when members move away from an insurer. FHIR API is not mandatory here.  

  • Bulk Access API:

    This method allows for large volume of patient data to be shared through FHIR like clinical data sent to analytical data warehouses, healthcare organizations exchanging data, or data sent to regulatory authorities. This API could prove beneficial for health plans.   

  • Prior Authorization Support API:

    This API is where providers submit a prior authorization request directly from the EHR/PMS system. This method is cost-effective for both payers and providers and helps speed the prior authorization which in turn helps providers deliver quality care to the patients/members.  

  • Document Lookup service API:

    This is useful to payers when a member/patient is about to get treatment, the coverage information is sent to the provider. Providers can take a judgment call on what treatment would cater to both patients’ health and is within their coverage limits.   

Related:   Reducing Operational Burden with FHIR APIs – Part 1

Business Rules Engines (BREs)

A business rules engine is a software system that executes one or more business rules in a runtime production environment. These are usually part of the business process systems. These are much more advanced automation engines compared to RPAs and APIs. They can automate tasks that involve complex decision-making and logic.   

Applicability of BREs in Healthcare Payer Automation:

  • When Selection of Health Plan for members needs various parameters to be considered, like, State, Age, Rating, Previous claim info, etc. 

When to Not Choose BREs for Payer Automation?

  • When Tasks that need automation are manual mundane tasks  


  • Mundane Tasks related to Claim processing like, Data entry, data conversion, claim verification  
  • Notifications Tasks Related to Member Engagement Apps 

Why do Health Plans Need BREs? 

  •   Enrollment System:

    Healthcare insurance enrollment is a complex initiative in which multiple validations are performed at different stages of application processing. This is commonly done with Medicaid and Medicare payers, as this parameters to suit these members would be different compared to members from non-Medicaid and Medicare payers. Some example of critical business rules are Age, rating type, state specific, etc. 

  • Claim Life Cycle Management System:

    This system is logic heavy, and the claim adjudication process often requires highest numbers of permutations of business logic as it is applied to various geographies, providers and policy benefits. BREs allow users to check for claim history without loading entire claim data and it helps with overriding benefits limits at multiple levels and more. 

Related: Improve Payer Reporting Efficiency Through Automation 


 All 3 solutions are vital in the functioning of payer operations without a hitch. However, RPA and APIs are pivotal solutions for a smooth payer operation. Nalashaa has been in the US healthcare space for over a decade armed with US healthcare regulatory and technology experts. Our regulatory and software solutions include- Interoperability (FHIR, USCDI, HL7,etc), API solutions, Member Engagement solutions, Claims automation, etc.  Drop your info at and infuse automation in to your payer systems, today. 

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Prateek Shetty

Prateek Shetty

Prateek is a B2B tech marketer with a keen interest in content marketing. B2B writer by day, Netflix junkie & gamer by night.

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