success story

Fortune 500 Company Automates Its Claims Routing for Increased Productivity

Our client is a FORTUNE 500 company with headquarters in Tampa, Florida. They provide managed care services for government-sponsored health care programs (e.g. Medicaid, Medicare and Medicare PDPs). The client's manual process for claims routing suffered from issues with manual workload assignment and constant claim misrouting.

We collaborated with our client to eliminate errors and build efficiency by automating their claims processes and sunsetting their in-house legacy application.



The Challenge

The client was using excel sheets and manual processes for claims routing and exception handling distribution. There were several challenges associated with this limitation:

  • Poor visibility and tracking of claims holds
  • No reconciliation ability
  • Inability to implement routing rules
  • Issues with manual work assignment and constant claim misrouting
The Solution

We designed and built a claims application that is powered by Pega Claims Workstation +. Key features include:

  • Consumption of all claims holds from the client legacy application, Xcelys
  • Ability to manage routing rules, priorities and work assignments
  • Automated claims routing to internal resources and vendors
  • Electronic feeds of claims to appropriate vendors
The Solution
The Benefit
  • 99.8% correct hold reconciliation (Pega/Xcelys)
  • Implementation of real-time claims holds routing
  • Reduced interest payments for claims by 10%
  • Increased productivity and throughput by +30%
  • Improved inventory management by ~2hr/day (20%)
  • Improvement in accuracy of claims hold routing by +25%
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