Introduction
A major national health plan was experiencing costly inefficiencies due to mismatches between the provider data system and their claims processing engine. These errors were affecting as many as 1 million claims annually, delays, penalties and manual intervention. were affected. Firstsource, as a long-time operations partner was asked to step in to ensure accurate data matching, reduce errors and improve first-time match rate.
Challenges
The client faced serious operational and financial risks due to mismatches between provider data and claims systems, leading to errors, delays, and revenue leakage:
- High claim fallout: Nearly 1 million claims annually were dropping out of the process due to mismatched provider data.
- Costly manual intervention: Frequent errors required manual rework before adjudication, slowing down operations.
- Penalty exposure: Delays increased the risk of interest costs and regulatory penalties.
- Revenue leakage: Errors directly contributed to lost revenue opportunities and higher cost-to-collect.
- Reputational risk: Ongoing inefficiencies threatened provider trust and overall plan performance.
How We Made It Happen
To address the client’s data mismatches and improve auto-adjudication, Firstsource combined process expertise with proactive validation and system synchronization measures:
- Process-wide analysis: Drew on Firstsource’s manual fallout teams, operations experts, and client IT to map the entire provider data–claims matching process.
- Fixing logic failures: Identified disconnection points and specific logic gaps in commercial claims matching; implemented enhanced process controls and standardized workflows.
- Proactive data validation: Introduced weekly provider demographic spreadsheets for validation, correcting root issues and synchronizing data across all systems.
- Triggering accurate routing: Re-entered provider IDs and address sequence numbers to retrigger system logic, ensuring claims adjudicated automatically instead of falling out.
- Comprehensive synchronization: Updated address, location codes, segments, and payment information across relevant systems to maintain alignment and ensure reprocessing success.