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.
- 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.
- 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.
- 50% Betterment in real-time adjustment & adjudication for providers
- 68% Improvement in auto-adjudication
- 35% Improvement in Claims processing
