RP Sanjiv Goenka Group

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

The challenge: Reduce payment inaccuracies and losses due to manual processes

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

The client’s complex manual adjustment process led to increased time to pay and poor payment accuracies, in turn leading to over/under payments to members. In addition, the healthcare company used a reactive checking and monitoring process. The errors were identified and fixed only after claims were finalized and the checks were cut.

The Health Plan’s goal was to reduce errors and claims expenses due to manual processes.

The solution: Automate core processes to identify and fix errors

To tackle the fraudulent claims and identify erroneous claims, Firstsource deployed an intuitive Robotic Process Automation (RPA) powered Virtual Auditor solution that helps validate 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 automate core processes, identifying, analyzing claims and maximizing recoveries. It helped the client analyze an average of 12000 global error databases on a monthly basis.

We were also able to help in identifying potential auto-correct logic 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.

The result: Improving efficiencies and overall Member and Provider experience

The RPA-powered Virtual Auditor solution delivered impressive results including:

  • Improved overall quality and TAT
  • Seamless claims tracking with a single click while eliminating unnecessary claim routings
  • Improved OAR (Overall Accuracy Ratio) Quality from 99.32% to 99.82%
  • DPMO (Defects Per Million Opportunities) reduced from 5689 to 1839

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

Business impact


of errors auto identified and auto fixed by Virtual Auditor


drop in overall error rate from 68 in 10,000 down to 18


of adjustment team’s effort automated


Volume reduction in internal adjustment

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