How a leading healthcare provider automated
1.4 million claims a year with 100% accuracy

It's the use of automation bots and standardized business rules to handle high-volume, multi-step claims tasks, like validation, coordination of benefits, and adjudication, without requiring manual review of every claim. Rather than a person checking each claim by hand, the system applies consistent decisioning logic to approve, deny, or flag claims for exception handling.

Coordination of benefits determines how a claim should be split or sequenced when a patient has more than one insurance plan, requiring accurate matching of primary and secondary member information. It's historically been hard to automate because it depends on data consistency between two separate claims and payers, any mismatch between primary and secondary data can lead to an incorrect submission or a denial.

DRG-based adjudication errors typically stem from inconsistencies in coding, length-of-stay validation, or fee verification, small discrepancies that are easy to miss manually but that directly affect reimbursement accuracy. Automating revenue code validation and fee matching against standardized rules removes much of the manual judgment where these inconsistencies tend to creep in.

High accuracy comes from replacing manual, judgment-based steps with standardized, rule-driven validation applied consistently across every claim, denial code checks, financial responsibility validation, and DRG rules all run the same way every time. In this engagement, that consistency across the full validation and adjudication process resulted in 100% accuracy on automated claims. Want to understand what it would take to reach that level of accuracy in your own claims environment? Consult with our experts to talk through it.

Volume capacity depends on how many validation steps are automated and how standardized the underlying business rules are, but in this engagement, the automated workflow processed more than 1.4 million claims annually. Scaling to that volume required integrating multiple validation steps (allowed amounts, COB, DRG adjudication) into a single, unified workflow rather than running them as separate manual processes.

This depends on how many manual touchpoints existed in the original process, from claim validation to exception handling to DRG review, but in this engagement, automation delivered the equivalent of more than 47 FTEs in capacity savings. Curious what capacity savings could look like for your claims team? Consult with our experts to map it against your current volume.

Yes, primarily by catching the data inconsistencies and validation gaps that lead to denials and rework before a claim moves further down the pipeline. Standardized, rule-driven decisioning applied consistently across every claim closes the gaps that manual, judgment-based processing tends to miss, especially in areas like COB where a single mismatched field can cause a denial.

Standardizing decisioning through consistent business rules, rather than relying on individual judgment calls, creates a more auditable, repeatable process, which reduces the operational risk that comes with inconsistent manual handling. In this engagement, that consistency across claim validation and adjudication strengthened compliance while also reducing the rework and revenue leakage tied to non-standard handling.