Claims Automation Saves $1.5M for Leading Payer
About the Client
- Plan Type: Medicare & Medicare Advantage
- Plan Size: 10M+ members
- Geography: National
Issue
One of the nation’s top five payers embarked on a comprehensive claims transformation initiative, needing to optimize claims prework processes in its commercial business.
The health plan also needed to rectify ongoing operational challenges and ensure timely claims processing for its Medicare Advantage plans, which was critical to maintain high Star Ratings—a key performance metric in the healthcare industry.
The payer lacked the internal technological and human expertise to implement validation mechanisms for prework in commercial claims processing. This step was vital to prevent inaccuracies in claims processing, including payments incorrectly routed to providers not associated with the claim, impacting member benefits.
By addressing these persistent challenges, Sagility helped the client reduce processing delays, minimize errors, and improve overall compliance with industry regulations.
Action
The collaboration aimed to enhance workflows through advanced analytics, technology-driven solutions, process reengineering, and human expertise.
Sagility focused on robotic process automation (RPA) opportunities, particularly in prework processes for Commercial claims and pend code workflows in Medicare Advantage claims.
Technology professionals analyzed and validated processes for seamless RPA implementation. They designed architecture frameworks, developed solutions, conducted testing, and documented prework and pend code automation workflows.
Automation solved edits through rule-based validations for stakeholders, billing, and benefits coordination. Pend code automation tackled payment validation inefficiencies, particularly missing referral authorizations, categorizing claims, and applying automated validation to prevent errors.
Powered by 50 bots, the system addressed processing inefficiencies and inaccuracies. The deployed solutions accelerated turnaround times and strengthened service quality for members and providers.
Impact
The RPA deployment established a foundation for operational improvements.
The project generated several outcomes including:
- $1.5 million in annual savings
- 7 million claims processed annually through RPA
- 22% improvement in operational efficiency by reducing average handle time from 180 seconds to 140 seconds
- 30% of agents reallocated to higher-complexity cases
- 10% rework reduction
Sagility’s technology & process solutions also delivered multiple qualitative results:
- Enhanced automation and improved process efficiency optimized workflows and overall performance.
- Rule-based automation reduced errors and eased downstream workloads.
- Automation accelerated claims processing, cutting turnaround times and boosting operational efficiency.
- Streamlined workflows ensured compliance with turnaround time requirements, reducing risks that could impact Star Ratings.
- Automated validation ensured regulatory adherence and improved claims accuracy.
in annual savings
claims processed annually through RPA
improvement in operational efficiency
