Claims Automation Saves $1.5M for Leading Payer

Smooth healthcare claims processing is a challenge that even the largest healthcare payers can find difficult to navigate. The challenge became a critical issue for one of the top five payers in the industry, who requested Sagility’s help to improve their claims processes.


Claims Troubleshooting

Smooth healthcare claims processing is a challenge that even the largest healthcare payers can find difficult to navigate. The challenge became a critical issue for one of the top five payers in the industry. Sluggish turnaround times, misdirected payments, and misaligned member benefits took a significant toll.

Not only were these errors eroding their reputation, but they also cast a shadow on their coveted Star rating. Realizing the urgency and magnitude of the problem, they turned to Sagility, hoping to leverage their expertise to bring much-needed transformation to their claim pre-work processes.


Claims Troubleshooting

An exhaustive troubleshooting process was the first crucial phase of the solution. Sagility fielded a team of ten design and development specialists, deploying 25 bots to dissect every portion of medical and hospital claims at the prework stage. This robotic process automation (RPA) approach was an aggressive strategy designed to streamline the workflow and eliminate inefficiencies.

The RPA bots were instrumental in deconstructing the claim process. Each bot had a specific role: validating provider and subscriber details, cross-checking billing information, scrutinizing the coordination of benefits, and ensuring the accurate determination of content cleanliness. This digital workforce was configured to work non-stop, around the clock, meticulously scanning claims for discrepancies or irregularities. But it wasn’t just about technology.

Sagility’s human team was there every step of the way, supervising, assessing, and refining the process. The human-bot collaboration was rule-based, creating a systematic workflow that ensured high precision. These rules, embedded in the bot’s programming, provided that all steps adhered to compliance standards and operational best practices, augmenting the accuracy and speed of the process.


End-to-End Processes

Sagility’s teams identified a striking inefficiency: a startling number of payments were being authorized and made without a proper referral, a glaring error causing a ripple effect of complications, including unnecessary rework and copious amounts of time-consuming communication.

We deployed a categorical approach. They restructured the claims process by categorizing them according to their complexity and type. Simultaneously, the validation process was automated, reducing the chances of human error and improving turnaround times.

Eliminating duplicate and follow-up logic meant that claims could be identified for payment faster, drastically improving overall operational efficiency.

Furthermore, the automation created an organized, easily accessible digital log of processed claims, making a more transparent, traceable process. This traceability reduced the chances of fraud, improved audit compliance, and significantly enhanced the overall end-to-end process, leading to more accurate and timely client payments.

With the revamped processes, Sagility accelerated the entire claims cycle, from initial submission to final payment. They transformed a system previously riddled with inefficiencies into a finely tuned, automated process that reduced costs, boosted productivity, and significantly improved payment accuracy and turnaround time.


By combining claims troubleshooting, root cause analyses, and actionable insights, Sagility revolutionized the payer’s claims process.


Efficiency Gains

Trimmed 40 Seconds Off Initial 3 Minutes of Processing Time



Per Year

7+ M


Processed Efficiently and Accurately

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