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How a BPO used Process Simulation to Transform Claims Management for US Health Insurers
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How a BPO used Process Simulation to Transform Claims Management for US Health Insurers

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  1. This is it.

Silico is working with a BPO (Business Process Outsourcing) company that manages claims for numerous US health insurance providers.

They currently use process mining to understand their processes but struggle to understand how they can become more efficient when claim volumes spike at the start of each year.

Moreover, they want to understand how to create further efficiencies within the process using automation and their transformation team.

The BPO turned to Process Simulation to determine the best process changes to drive efficiency, exactly determining the impact of process changes through simulation.

Silico helps BPOs go from process mining to value in just four weeks

Silico enabled the company to move from process mining to action over just four weeks through the following steps:

  1. Importing the process mining graph and analytics to generate a Digital Twin of the insurance claims process.
  2. Expanding the Digital Twin to incorporate volume forecasting and financial analysis modules.
  3. Conducting forward-looking simulations to identify where issues will occur during claims spike to focus the transformation team’s efforts.
  4. Evaluating process changes that the team could implement straight away to prioritise changes and maximise the team’s impact on KPIs.

The process flow was imported from a process mining diagram into Silico. The BPO could now use Silico to experiment with the three key levers they can pull to manage/improve their processes: resourcing, automation and transformation.

Managing volume spikes with dynamic FTE resourcing

By December, the BPO company receives information from Healthcare providers about the spike in uptake. This gives the BPO minimal time to adjust and train FTE capacity to process claims during the peak period.

Using Silico, they can input the claims volume during spikes and determine the number of temporary FTEs required to reduce the time to process claims to a level acceptable to the customer. Using the interactive dashboard, the BPO can determine how many temps are required for the spikes and resource accordingly. The model incorporates training time, hence the small spike where the temps are not yet effective. By the end of February, the temps are then released, and we resume to ‘BAU’ FTE levels.

The interactive dashboard can also simulate the impact of larger-than-expected spikes (orange). This allows the BPO to ensure they are resourced for the situation in which claims spikes differ from past observations.

The dashboard below describes that with a higher-than-usual claims spike, the BPO will only experience an increase in claims processing times by one day with the same number of temps. The dashboard allows the BPO to find the sweet spot between the time to process and the cost of temps.

Using Silico to identify ideal candidates for automation saves $136k for the customer

The BPO operates a model where the customer will pay for the automation initiatives. However, the automation must provide a significant return on their investment through discounts on claims processed through automation. Before Silico, the BPO would run some basic maths to present to the customer and find it difficult to convince them of the benefits. With Silico, the client uses advanced optimisation technology to identify the best steps to automate and provides a customer-facing dashboard to make the business case for automation.

Three steps were identified for automation. The BPO understood the volume of claims that could be realistically automated through each step and decided on a reasonable discount to provide the customer. Their changes to the process have been implemented in the Digital Twin.

Silico then ran its optimisation algorithms and identified the combination of automation initiatives resulting in the most significant cost reduction for the insurance client.

Silico found that two of the steps should be automated to their full potential. However, one should be automated to only 30% because the costs of further automation do not outweigh the discount they can afford to offer the customer.

Over the next two years, implementing these automations will result in ~$136k in savings for the customer plus a reduced processing time for the BPO, meaning less FTE will be required in the future - a win-win for both parties.

Identify process improvement opportunities beyond automation

The BPO now wanted to find further opportunities to ensure the transformation team can continuously improve the process without interruptions. Silico allows the customer to determine the benefits before they are implemented, meaning there is no delay to recapture data in their process mining tool. The client wanted to explore reducing wait time, e.g. for more details from hospitals, in some process steps. Process mining has told them two undesirable activities to explore. It has highlighted that the step with the highest wait time should be reviewed – so the team simulated the benefit that would bring over two years. They then compared this to a step with a lower wait time but more volume. This provided more benefit than slower the step recommended by process mining.

The BPO has reduced their turnaround time from ~6.5 days down to ~4.5 using a mixture of both automation and transformation teams reviewing wait times. They saved their customers significant time and money by using an accurate and trusted model to identify where they should best spend their budget to improve the process, driving value for themselves and their policyholders.

Simulate your processes for maximal impact on business outcomes

Silico introduces a groundbreaking avenue for BPOs striving to refine processes with precision and cost-effectiveness. In just four weeks, Silico built on existing process mining insights and analytics to generate a dynamic Business Process Simulation, aligning your process with critical KPIs and strategic goals.

With Silico, you can seamlessly test process changes within a virtual space, analysing their effects and uncovering the ideal combination of adjustments necessary to realise significant savings, reduce processing times, and drive enhanced profitability. Elevate your process efficiency through Silico’s innovative approach.

Connect with us today to explore how we can empower your BPO’s optimisation journey.

Contact for a demo or to learn more about how process simulation can help your business.