Money from insurers arrives sooner because the claim is right the first time, and you can see which insurer is holding how much.
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Hospitals & clinics · 11 / 14
Insurance claim and records workflow
Claim documents complete the first time, each insurer’s form filled on its own, and the claim followed until the money arrives, all inside the hospital’s systems under PDPA.
Hospitals & clinics “One insurance claim means collecting documents from five departments, filling each insurer’s own form by hand, and getting it bounced for missing data.”
The problem
A claim starts at the finance desk, and the documents are everywhere else. The medical certificate is with the doctor, the medication list with the pharmacy, the test results with the lab, the receipt with finance. Claims staff walk or phone from department to department, then type the same data into whichever form that insurer designed.
One wrong field, a diagnosis code that does not match the procedure or a receipt total that differs from the form, and the claim bounces. That takes weeks to learn. So the hospital carries a large receivable from insurers at all times, and nobody can say which case is held up and why.
How we solve it
We set up the agent inside the hospital network, connected to the HIS and the finance system with the permissions IT defines. When a patient on an insurance scheme is discharged, the agent gathers that case’s documents from every department into one pack and fills in the form of the insurer the patient uses, from the template we set up for each insurer.
Before sending, the agent checks that the documents are complete for that insurer and that diagnosis codes, procedures and amounts agree with each other. Any field that does not line up is pointed out to the claims officer with the reason. The officer reviews the finished pack and presses send. After that, the agent follows the status with the insurer; if the claim is rejected it says at once what is missing and prepares the corrected pack.
Anything touching the patient or the money still passes through a person. The agent does not submit claims on its own and does not edit medical data. Patient data stays in the hospital’s systems under PDPA and health-data rules, and every view and every entry is logged for review.
How it runs
Work comes in from
- HIS and medical records
- Receipts from the finance system
- Each insurer’s requirements
- Replies from the insurer
What the AI does
- Gather the case file from every department
- Fill the insurer’s form
- Check completeness and consistency
- Follow the claim until it is paid
Where it lands
- A finished pack for the officer to send
- The insurer’s claim system
- Alert on rejection
- Monthly receivables report
Before and after
Before
After
Staff walk to five departments for one case
The claim pack is assembled from the HIS at discharge
Bounced for missing data, found out weeks later
Errors are pointed out before send, and a rejection is flagged at once
Nobody can say why the insurer receivable is held up
Receivables reported by insurer and reason, every month
What you get
- 01
An agent pulls the medical certificate, receipts, medication list and test results from the HIS and the finance system into one claim pack per patient
- 02
Each insurer’s form filled in its own layout, for private, group and government schemes
- 03
Completeness and consistency of diagnosis codes, procedures and amounts checked before a staff member presses send
- 04
Claim status followed with the insurer, with an alert on rejection saying what is missing and a confirmation when the money lands
- 05
A monthly report of open claims, receivables outstanding, and which insurers reject most and why
Who gets what
Runs inside the hospital network, connected to the HIS with the permissions IT sets, read-only to begin with. Patient data never leaves your systems, and every access is logged under PDPA.
Claims staff stop walking for documents and stop retyping the same data into a different form for each insurer. What is left is reviewing the finished pack and pressing send.
Who this fits
Private hospitalsSpecialist clinicsDental centresAesthetic clinicsHospital groups with several sites
Connects with what you already run
HISInsurer systemsHospital finance systemEmailLINEMicrosoft 365
Development process
- 1
Discover
Requirements, users and success metrics, with scope and price fixed before we start.
- 2
Design
UX and system architecture; the prototype is approved before anything is built.
- 3
Build
AI-accelerated sprints with a demo every week, reviewed by senior engineers.
- 4
Test
QA, security and performance verified against the agreed scope.
- 5
Launch & care
Production deploy, team training, and a monthly care plan.
Turn your business problem into a system that works for you
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