Case Study | Healthcare Payer

Automated Claims Management System

Building a claims matching system to overcome data complexity and variability leading to inaccuracies and mismatches in prior authorizations.

Overview

A national health insurance provider faced challenges with growing complexity in authorization services, as their legacy claims system struggled to accurately match services rendered to prior authorizations. 10Pearls developed a claims matching system that leveraged automation to accurately cross-match claims with prior authorizations.

Increased claims accuracy to 98%
with seamless processing

Achieved $17M savings in 4 months
by reducing inefficiencies

Challenge

The legacy claims system was increasingly unable to match services rendered to prior authorizations due to growing complexity in authorization services. This resulted in frequent inaccuracies, inefficiencies, and payment errors, with data complexity and variability further compounding these issues. These challenges led to delays in claims processing, causing financial and administrative burdens for both providers and patients, and with system replacement not being a feasible option, the need for an effective solution became even more critical.

Solution

10Pearls developed a new claims matching system leveraging Appian, a leading process automation platform. The solution cross-matched claims against existing prior-authorizations to determine whether the claim should be paid or not. The system enabled precise control over matching prior authorizations to claim lines, routing match exceptions to enable the opportunity to resolve issues and resubmit the claim. Overall, the implementation of the new system resulted in reduced payer implementation and maintenance costs as well as reduced leakages for incorrect payments.

Customer

Leading national healthcare provider

Services

Tech Stack

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