A Fortune 500 Healthcare Payer based out of Long Beach, California

Business Challenge

The client encountered several key challenges, namely,

  • A deficient auto-adjudication rate of just 50% after the execution of back correction scripts.
  • Preparation for the claims batch cycle involved running nearly 400 backend scripts, contributing to operational complexities.
  • Backlog for fiscal agents due to slow report generation.

Compounding these issues was a low processing rate for claims, leading to a backlog in the daily batch cycle.

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  • Improved the claims management systems to help enhance auto adjudication and claims backlog
  • Conduct a comprehensive assessment of the claims flow, pinpointing components requiring replacement or enhancement. 
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  • To meet the client’s requirements to optimize processes, the following methodologies were followed:
    • Dedicated and functional platforms developed for each module.
    • Platformized through decomposed requirements in Claims, Payments, and Ancillary areas.
    • Automation to streamline workflows previously managed through backend scripts.
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Business Value
  • 50%  Betterment in real-time adjustment & adjudication for providers 
  • 68%  Improvement in auto-adjudication 
  • 35%  Improvement in Claims processing