Automating payer audit tracking helped a US Health Plan in auto-fixing 50% of the claims errors


Our client, a Fortune 500 managed healthcare company based out of Minnesota, was losing close to $15 million per year, due to mispaid claims. The client was processing close to 283,000 claims annually. 24% of these claims were routed to an internal adjustment team, resulting in higher turnaround time and additional costs.

The health plan’s strategic initiative was to reduce claims expense. Given below is how Firstsource’s robotic process automation helped in preventing claims leakage, while nurturing a happy customer relationship.

Business challenge

Client’s complex manual adjustment process led to increased time to pay and poor payment accuracies on over/under payments to members.

The healthcare company’s existing process of checking and monitoring was reactive. The errors were identified and fixed only post finalization of claims and check-cut process.

Firstsource solution

To tackle the fraudulent claims and identify erroneous claims, Firstsource designed an intuitive robotic process automation powered Virtual Auditor solution that helped in validating 100% of the claims. The automation solution helps in scrutinizing 74 different potential error opportunities and validating suspects in real time.

Firstsource’s Virtual Auditor solution helped in automating core processes, identifying, analyzing claims and maximizing recoveries.

Firstsource helped its client in analyzing an average of 12000 monthly global error databases. We were also able to help in identifying potential auto correct logics for 50% of these global errors. Our solution completely transformed the claims audit process, proactively identifying errors, auto fixing, improving productivity and efficiency, while also reducing cost.

Firstsource has been providing claims adjudication services to the managed health care company, over the past several years. We have built a flawless claims processing environment, leveraging innovation, automation and process excellence.

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Business impact

Our solution delivered some impressive results and metrics, including:

  • 66% volume reduction in internal adjustment
  • 40% of adjustment team’s effort is automated
  • 50% of errors are auto identified and auto fixed by our Virtual Auditor
  • Automation and Innovation helped in improving overall quality & TAT improvement
  • Seamless tracking of claims, through a single click while eliminating unnecessary claim routings
  • OAR (Overall Accuracy Ratio) Quality has improved from 99.32% to 99.82%
  • DPMO (Defects Per Million Opportunities) has reduced from 5689 to 1839

Customer satisfaction improved to 94.07%, on top of which we achieved the following results:


Volume reduction in internal adjustment

5689 to 1839

Reduced DPMO (Defects Per Million Opportunities)

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