Increasing Auto-Adjudication Rates for Contracted Provider Groups
Project Insight
Claims Processing Automation
Our client processed claims for contracted provider groups across a variety of products (Commercial HMO, Medicaid and Medicare Advantage). Variation and complexity in the contracts led to a very low auto-adjudication rate and higher staffing costs.
Solution Implementation
We worked with the organization to develop a robust contract ingestion and automation process to streamline payment rules configurations and identify opportunities for continuous improvement:
Contract Analysis: Created a system to streamline the identification and consumption of complex payment rules into the claims system based on provider contracts.
Auto Adjudication: Developed automated processes and QA reporting necessary to update claims records and pre-approve them for payment.
Advanced Analytics: Developed advanced audit and process reports to identify opportunities for continuous improvement and future claims automation.
Results
The deployment of the system drastically improved the auto-adjudication rates and allowed significant growth at a lower headcount ratios:
Auto Adjudication Rate: Improved 65% over a 6-month period.
Enhanced Efficiency: The increase in auto adjudication rates allowed claim volume to increase significantly with minimal headcount. QA audit team was able to maintain review ratios with the same headcount.
This case study highlights our expertise in analyzing complex payment systems and developing and implementing automated adjudication solutions. Through process improvement, automation and advanced analytics we improved operational decision-making and efficiencies.
Domain & Technology
- Claims payment algorithms
- Real-time data integration
- Process automation tools
- Machine learning and advance analytics
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