1. / Healthcare Payer Saves Overpayments Worth $1.5M per Annum
Overview

Customers expect almost-instantaneous resolution to claims. Manual claims processing, while maintaining optimum levels of accuracy, creates profitability pressures for payers, leading to unforeseen delays, higher litigations, overpayments, and unsatisfied customers.
For this customer, manually auditing claims failed to stem revenue leakage and slowed down resolution times. They were looking to automate and streamline claims processes to optimize the number of human touchpoints and make the process faster and more accurate.

Problem

Manually auditing claims to check for overpayments was leading to:

  • Significant revenue leakage due to high cost of auditing
  • Failure to preempt overpayments, leading to post-claim litigations
  • Backlog pile-up due to slow claims processing
Solution

Apexon brought onboard ApexClaims, a proprietary advanced analytics platform embedded with classification and anomaly detection models, to:

  • Integrate data from audit, call centers, recoveries, grievance and redressal, etc., for a 360° view of the claim 
  • Intelligently predict financially-erroneous claims and provide supporting documentation for overpayment
  • Automate sub-processes and optimize the adjudication process for human intervention
  • Integrate provider data management and membership risk management
Impact

With ApexClaims, the customer introduced cognitive capabilities and automation across its claims adjudication process that helped them:

  • Save $1.5M per annum in cost avoidance due to overpayment
  • Achieve 99.7% accuracy in adjudication, reducing errors by 50%
  • Reduce manual effort by 66%
  • Expand the scope of audit to 100% claims, up from 33% sampled earlier

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