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Revenue Cycle Management – Utilization Reviews Audit Request using RPA Automation


XYZ UR Audits is an independent auditing firm specializing in conducting Utilization Reviews (UR) on PQR Patient Accounts as part of their external auditing services.
The XYZ UR Audits are conducted monthly throughout the network, and they entail submitting multiple documents, including the Uniform Billing, Hospital Utilization Review Certification Sheet, Eligibility Form, and Remittance Advice. These documents are obtained from various internal and external systems, utilizing patient identifiers and account information, as well as the patient’s admittance and discharge dates. In the most recent audit, more than 300 accounts were reviewed, with each account necessitating the retrieval and submission of 3-4 distinct documents to the Medical Records department as .pdfs. These records are subsequently merged with the patient’s clinical Medical Records and submitted through the XYZ portal.
rpa automation


  • Due to varying access limitations to certain patient data, multiple teams are involved in the process. However, the decentralization of the process increases the risk of missing audit deadlines.
  • Several teams are engaged in the manual processes, including Patient Accounting, Medical Records, and Case Management.
  • Teams have a limited capacity to complete processes, typically requiring a turnaround time of around two weeks.
  • The process lacks streamlining between hospitals.


An RPA Automation solution was designed to automate gathering and consolidating patient information into a single file, allowing the latter to be shared with third-party auditors to serve as input for the audit.


rpa automation
Automating the process of gathering documents for an audit not only saves the valuable time of multiple team members but also enables them to concentrate on activities that add more value.
The results included:
  • Opportunity to leverage automation as a response to new leadership requests to streamline processes for hospitals.
  • Reduced load across cross-functional Teams.
  • Shortened response time to Auditors.
  • Improved optimization & streamlining of the process between hospitals.
  • Enhanced scope of solution scalability across all hospitals.


Implementing RPA Automation for conducting utilization reviews has significantly enhanced the efficiency of the organization’s revenue cycle management. By automating the document-gathering process for audits, the RPA Automation solution has considerably reduced manual work, saved time, shortened response time to auditors, and alleviated the workload of cross-functional teams.