Helping a large health care organization orchestrate AI powered claims operations

The client, a health care company, was struggling to improve medical claims operations despite significant investments in traditional automation. With their claims’ auto-adjudication rate stalled, the company incurred multiple millions of dollars in annual operating costs, overpayments, and penalties. The organization sought a scalable solution that could help increase automation, improve accuracy, accelerate claim processing, and deliver measurable business value without overhauling existing claims systems.

Increased automation and operational efficiency 

• The solution automated approximately 6 million claims annually. This reduced processing times by 20-35% and helped enable claims to be processed up to 20 times faster than previous manual workflows.

Improved quality and accuracy

• First-pass medical claims accuracy improved by 45%, while rework was reduced by 65%. Business subject-matter specialists were also able to help validate AI-generated workflows in days instead of months, accelerating deployment and adoption.

Financial and organizational impact

• The organization achieved operational savings, reduced reliance on manual claims processing, and gained greater visibility into claims quality and performance. The solution also helped uncover process and system optimization opportunities.

Sustainable, ongoing transformation 

• The AI-powered solution can continuously learn and adapt to changing business requirements, supporting ongoing improvement, easier examiner training, and scalable expansion across additional lines of business.