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How a healthcare payer cut resolution time and saved $10.1M
A leading healthcare payer processed thousands of appeals monthly through complex, manual workflows, each case taking up to 37 minutes to resolve, delaying outcomes and increasing compliance risk. Virtusa delivered an AI-led workflow automation solution that streamlined the process, cutting resolution time, boosting accuracy, and strengthening audit readiness.
Appeals agents at a leading healthcare payer managed thousands of member appeals every month, often tied to high-stakes healthcare decisions. Behind every appeal was a patient waiting on a decision that could directly impact their care, coverage, or cost. But for the agents, getting to that decision wasn’t easy. Each case required searching multiple platforms, reconciling fragmented data, and documenting every step manually.
These repetitive, non-standardized workflows significantly slowed down resolution times, with some appeals taking up to 37 minutes to complete. The delays, combined with manual effort, drove up operational costs, draining both budgets and analyst capacity.
The lack of automation increased the risk of human error and made it challenging to meet service-level expectations and regulatory timelines consistently.
Even minor delays or documentation gaps in appeals tied to financial reimbursements and clinical authorizations had a severe downstream impact: member dissatisfaction, provider friction, and audit vulnerabilities. The constant strain on agents contributed to fatigue, increased turnover, and inconsistent service quality. The healthcare payer partnered with Virtusa to reimagine their appeal processing.
Avg. appeal processing time
As a strategic partner, Virtusa implemented and now manages the ClarifAI platform end-to-end. This generative AI (genAI)-powered solution automates repetitive steps, improving data accuracy and enabling real-time support for appeals specialists.
The AI solution proactively surfaced the correct data, documents, and subsequent actions based on the context of each appeal, resulting in fewer delays, reduced errors, and dramatically lower operational burden on their human counterparts.
Key AI-led enhancements included:
Together, these AI capabilities transformed appeals from a fragmented, manual process into a streamlined, intelligent workflow, accelerating turnaround times, improving accuracy, and alleviating compliance pressure.
The AI-led transformation delivered by ClarifAI significantly improved operational performance and reduced expenses across the appeals lifecycle, supporting the payer’s Cost to Serve initiative. It helped the healthcare payer:
With the success of the appeals transformation, the healthcare payer is extending its partnership with Virtusa to modernize the Submit Order process—a critical intake step for claims and appeals. By applying the same AI-led, workflow-first approach, Virtusa will streamline the collection and routing of supporting documentation, aiming to further reduce cycle times, enhance compliance, and improve both provider and member experiences.
The decision to expand the engagement reflects the payer’s trust in Virtusa’s end-to-end AI engineering, deep healthcare domain expertise, and outcomes-focused delivery model. From scalable automation to KPI-aligned execution, Virtusa has demonstrated the ability to design and manage complex, regulated workflows, making it a strategic partner in the payer’s broader transformation agenda.
faster appeals processing
unlocked in savings
routing accuracy
solution accuracy
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