Sagility Improves AA Rate, Reduces Interest, Penalties by 30% for Leading Blues Plan
About the Client
- Plan Type: Blue Cross Blue Shield Multi-Line (Commercial, Medicare Advantage, Medicaid, ASO)
- Plan Size: 5M+ members
- Geography: California
Issue
A leading Blue Cross Blue Shield plan faced multiple issues in its claims processing business segment, including work on high-deductible claims. Problems surfaced as the plan encountered multiple inefficiencies while handling more than 32,000 claims daily. Compounding this issue, there were more than 900 aged claims every day, which added $1 million in annual interest and penalties.
The payer also experienced significant difficulty managing the corrected claims process, which involves resubmitting an insurance claim to address errors or omissions in a previously submitted claim.
In addition, system limitations and inefficient high-deductible claims processing led to costly rework. Late paper claims further exacerbated issues, contributing to provider abrasion and lower member satisfaction.
While the plan had a strong desire to implement technological solutions, the team lacked the internal expertise and infrastructure to do so.
Action
Sagility partnered with the Blues plan and led a comprehensive analysis of the payer’s processes, focusing on claims. The assessment discovered that the plan’s corrected claims process represented a significant opportunity for technological transformation and improvement.
We optimized the corrected claims processing with:
Enhanced electronic submissions to reduce paper dependency and improve auto adjudication rates
Reduced rework through better denial recognition and Maximum Out-of-Pocket notifications in the Facets platform
Improved auto adjudication rates for multiple scenarios, including anesthesia claims using correct pricing formulas
Better recognition of high-deductible claims in the Facets platform, specifically those greater than $3,000, for post-processing reviews
Enabled GenAI live chat for payer team members to increase claims resolutions
Formed a dedicated processing assistance team for smoother workflows
In its entirety, the Sagility solution maximized the payer’s ability to manage operational workload and ensure overall efficiency and accuracy for the entire claims team.
Impact
Sagility’s transformational process helped the Blues plan better align day-to-day claims work with its vision to reduce interest and penalties, while enhancing claims processing with auto adjudication.
Plan representatives said this new effort marked a significant step forward in reducing costs and improving accuracy.
Key Results delivered include:
- Improved auto adjudication rate by 0.25%
- Reduced inquiries and escalations by 5%
- Lowered aged claims inventory from greater than 2.0% to less than 1.0%, cutting interest and penalty costs by up to 30%
- Faster processing and improved accuracy, boosting member/provider satisfaction
Sagility’s auto adjudication improvement solution is transforming claims management for this Blues plan by automating processes and scaling claims handling. This accurate and efficient claims program consistently exceeds the payer’s expectations.
These achievements highlight the transformative power of combining human expertise with strategically deployed automation technologies. By infusing operations with precision, efficiency, and scalability, Blues plans can elevate productivity, while ensuring exceptional accuracy.
reduced inquiries and escalations
lowered aged claims inventory to less than 1%
reduction in interests and penalites
