Claims Processing Automation
Automated 80% of medical claims processing for a health insurance company, reducing processing time from days to minutes.
Key Results
The Challenge
A regional health insurance company processing 2 million claims annually was struggling with manual claims adjudication. Processing times of 5-7 days were frustrating providers and members, while error rates were driving up costs and compliance risk.
Key Pain Points
- Average claims processing time of 5-7 days
- 12% error rate in claims adjudication decisions
- 200+ staff dedicated to manual claims review
- Provider complaints increasing 30% year-over-year
- Regulatory scrutiny over claims processing accuracy
Our Approach
We built an intelligent claims processing system that automates routine claims while routing complex cases to specialized reviewers with decision support.
Phase 1: Document Intelligence
- Implemented OCR and document classification for incoming claims
- Built NLP models to extract key fields from unstructured documents
- Created validation rules engine for claims data quality
- Integrated with existing claims management system via APIs
Phase 2: Auto-Adjudication Engine
- Developed ML models to predict claim approval/denial
- Built a rules engine incorporating plan benefits and medical policies
- Implemented automated coding validation and correction
- Created confidence scoring to route uncertain claims to human review
Phase 3: Reviewer Workbench
- Built decision support dashboards for claims reviewers
- Implemented case prioritization based on complexity and value
- Created automated audit sampling and quality assurance workflows
- Deployed feedback loops to continuously improve model accuracy
Technical Implementation
Architecture Highlights
- Document Processing: AWS Textract + custom ML models for extraction
- Rules Engine: Drools for benefit determination and medical policies
- ML Platform: Custom PyTorch models for adjudication prediction
- Integration: RESTful APIs and HIPAA-compliant message queues
- Workflow: Camunda for orchestration and case management
Compliance Integration
- HIPAA compliant processing with PHI encryption and access controls
- Complete audit trail for all adjudication decisions
- Explainable AI for regulatory inquiries and member appeals
- Automated compliance reporting for state regulators
Results
The system launched in 12 months, dramatically improving operations:
- 80% of claims auto-adjudicated without human intervention
- Processing time reduced from 5-7 days to under 30 minutes for auto-adjudicated claims
- 65% reduction in adjudication error rate
- $12M annual savings from reduced manual processing and error correction
Client Testimonial
"We were skeptical that AI could handle the complexity of claims adjudication, but Gojjo Tech proved us wrong. The system is more accurate than our manual process ever was, and our providers love the faster turnaround."
— VP of Claims Operations