Case Study

Improving Auto-Adjudication Rates

This high growth Medicaid and Medicare Insurer serving nearly 3 million members across thirteen States found low auto-adjudication rates and high manual processing costs unsustainable and a barrier to effective growth. It sought new solutions to improve claims auto-adjudication rates and processing efficiency without the complexity, time or cost of a full replacement of its core administration system. Financial drivers of the initiative included a savings of over five claims analysts for every 1% lift in auto-adjudication and the potential for a $240,000 per year annual savings on interest payments through improved adjudication accuracy and timeliness.

By leveraging Pega, the Insurer has achieved 16 points improvement in its claims auto-adjudication rates over two years resulting in annual savings equivalent to the cost of 90 claims examiners. “Business rules enabled us to decrease 80 percent of duplicate pends” says the Vice President of Technology. Plus, Claims Repair has also nearly eliminated the Insurer’s pends for No Authorizations and also provided new processing visibility, accuracy and control so the Insurer can avoid financial penalties. The Insurer plans on-going tuning and edits to yield further improvements.


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