Success Stories

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 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%