Claims Processing & Adjudication

The Challenge:

The client is one of the largest health maintenance organizations in the US providing comprehensive healthcare services to their members. They wanted to improve their claims processing capabilities, automate adjudication, and increase scalability to sustain an expected increase in claims volume in the upcoming years. The main objectives were to reduce the claims cycle time through minimized manual procedures and reduced operational costs for claims processing. An additional goal was to eliminate the existing backlog, accumulated over the last two months.

Due to the complexity of claims data entry and the rising cost of employee wages, the client was facing challenges in the timely processing of healthcare claims, dealing with arising volume of provider calls and controlling the accuracy of the overall claims entry and adjudication process.

Rapid settlement of claims required access to mounds of documents which was becoming difficult for the client to manage manually. The client needed a software solution that not only scans various claim documents with precision and intelligence but also provides a centralized platform for the secure storage of the documents to enable quick access, whenever required. A digitized approach was required in order to optimize the processes.


With a strong focus on reducing turnaround time per claim, an Electronic Data Interchange (EDI) claims conversion software was created for the client, which was fast, accurate and insulated from the frequent disruptions that occur during a typically day in the claims office. The EDI deployment helped the client concentrate on other critical tasks and substantially reduce 'paper handling". This cost effective solution created savings, provided operational efficiencies and improved the overall satisfaction with providers, members and staff.

“The claims processing BPO services reduced the cost of processing by 50%”


The claims processing BPO solution was successfully transitioned within one month. Implementing an associated EDI solution improved the business process efficiency and achieved substantially higher levels of productivity (40%) due to reduced time required for extracting information. The application also reduced the risk of processing inaccurate claims, thereby, improving the auto adjudication rate by up to 40%. The software allowed the client to validate, check and monitor each step involved in processing the claims and reduce the cost of processing by 50%. Additional benefits included faster and timely disbursements of claims, higher provider satisfaction and a reduction in provider calls.


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