Returning 23,100 hours a year to a plan’s claims teams.
A health plan with more than three million members kept its core claims system in place and automated the high-volume edits, adjustments, and coordination-of-benefits work around it, without replacing the core.
Savings are the customer’s own, projected over three years from the automated processes.
The bottleneck wasn’t the claims system. It was the manual work around it: edits, adjustments, and coordination of benefits that could be automated without replacing the core.
High-volume claims work was handled by hand.
Around the plan’s claims system ran a layer of edits, adjustments, and coordination-of-benefits work, tens of thousands of transactions a month, most of them repetitive and each needing a knowledgeable person to check it. That work absorbed experienced staff, and every rise in volume meant either slower processing or more headcount.
More volume meant more people. Coordination-of-benefits and edit work climbed steadily, and the only way to add capacity was to add staff.
Accuracy came at the cost of speed. Protecting quality meant more manual review, which slowed processing.
Experienced staff on rote work. Knowledgeable people spent their days on repetitive checks rather than judgment.
The core system wasn’t the problem. Replacing it would have meant a large, risky program without removing the manual work around it.
Routine work was automated. Exceptions stayed with people.
We started with the workflows that had a clear payback.
We ran discovery workshops across the claims-servicing operation to identify where the manual work was concentrated. Fifteen processes were evaluated for cost, effort, and payback. The workflows with the strongest business case were built first.
Those workflows were built on the technology the plan already ran. Approved rules handle the routine work, and anything that fails a check or needs judgment goes to a person. Every action is recorded, so the work stays auditable.
More volume no longer required proportional headcount.
The automation runs around the core claims system rather than replacing it. There was no system migration and no second record to reconcile. The plan kept the platform it already used and removed repetitive work from the teams around it.
As claims volume grows, the automated workflows can absorb more of the work without requiring headcount to grow at the same rate.
How much of your claims work is done by hand?
Bring us your highest-volume edit, adjustment, or coordination-of-benefits workflows. Bring us one of your highest-volume edit, adjustment, or coordination-of-benefits workflows. We will use your numbers to show you how much work it consumes today and what automation could change.