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: Medicaid, Medicare, and Medicare PDPs. The client used manual processes for claim routing and suffered from issues such as manual workload assignment and constant misrouting of claims. They set off on a journey to automate claim application with Virtusa as their partner of choice.



The Challenge

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

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

Designed and built claims application powered by Pega Claims Workstation.

Key features include:

  • Consumption of all claims holds from the legacy application, Xcelys
  • Ability to manage routing rules, priorities and work assignments
  • Deliver automated claims routing to internal resources and vendors
  • Provide electronic claim feeds 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%)
  • Improved accuracy of claims hold routing by +25%
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