Success Story healthcare

Healthcare Payer Saves Overpayments Worth $1.5M per Annum

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healthcare claims processes

Customers expect almost-instantaneous resolution to claims. Manual claims processing, while maintaining optimum levels of accuracy, creates profitability pressures for payers, leading to unforeseen delays, higher litigations, overpayments, and unsatisfied customers.

For this Healthcare Payer, manually auditing claims failed to stem revenue leakage and slowed down resolution times. They were looking to automate and streamline claims processes to optimize the number of human touchpoints and make the process faster and more accurate.

the Results

Key Outcomes

With ApexClaims, the customer introduced cognitive capabilities and automation across its claims adjudication process that helped them:

Save $1.5M per annum in cost avoidance due to overpayment
Save $1.5M per annum in cost
avoidance due to overpayment

Achieve 99.7% accuracy in adjudication, reducing errors by 50%
Achieve 99.7% accuracy in
adjudication, reducing errors by 50%

Expand the scope of audit to 100% claims, up from 33% sampled earlier
Expand the scope of audit to 100%
claims, up from 33% sampled earlier

Reduce manual effort by 66%
Reduce manual
effort by 66%

The challenge

3 key areas

Manually auditing claims to check for overpayments was leading to:

Post-claim Litigations

Post-claim Litigations Failure to pre-empt overpayments, leading to post-claim litigations

Revenue Leakage

Revenue Leakage Significant revenue leakage due to high cost of auditing

Backlog pile-up due to slow claims processing challenge

Slow Claims Processing Backlog pile-up due to slow claims processing

The solution
4 key areas

Apexon brought onboard ApexClaims, a proprietary advanced analytics platform embedded with classification and anomaly detection models to:

360° Claim View

360° Claim View

Integrate data from audit, call centers, recoveries, grievance and redressal, etc., for a 360° view of the claim

Predict Claims & Provide Documentation

Predict Claims & Provide Documentation

Intelligently predict financially-erroneous claims and provide supporting documentation for overpayment

Automate & Optimize Processes

Automate & Optimize Processes

Automate sub-processes and optimize the adjudication process for human intervention

Integrate Management

Integrate Management

Integrate provider data management and membership risk management

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