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HEALTHCARE

Automating Claims Processing and Transforming IT for a Major Health Plan


The Challenge

A large, not-for-profit health plan faced regulatory compliance issues, declining membership and downward trends in customer service metrics as a result of its aging IT systems and processes. While the management team realized it needed to reinvest to scale up the plan’s underperforming IT systems and processes, it also recognized the need for a rapid transformation. The organization engaged Cognizant to lead this transformation, given our deep experience in healthcare as well as our capacity to manage large-scale IT and business process transformation.


Our Approach

Because the organization was struggling with backlogged claims and interest charges were driving up its costs, our transformation efforts primarily focused on streamlining claims processing—which we tackled in three phases. In the first phase, we completely analyzed current and historical claims to identify patterns that led to rework. Then we corrected flaws in the plan’s policies and procedures while developing a process to “recycle” claims based on revised policies. Lastly, we automated some parts of the claims process using robotic process automation, implementing advanced algorithms to mimic human judgment and decision-making. We developed reusable assets that also can be used in other areas within the organization. We’re currently helping the plan develop a Center of Excellence to drive other digital solutions.

Legacy Systems and Processes Make Way for a New, Improved Platform

By taking complete ownership of the organization’s back-office systems and processes, Cognizant first stabilized and then ran these systems while developing a new, world-class platform. This helped to significantly improve the plan’s claims processing system while eliminating a substantial claims backlog. These improvements enable the client to focus on product development and market strategy, so it’s in a better position to compete and gain market share. Our three-phased initiative helps the plan pay claims promptly, reduce employee overtime and lower the claims inventory to near-zero levels.

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$900 million

in savings through selling, general and administrative expense reduction over seven years

15X

reduction in claims inventory

4X

reduction in average days in-house for pending claims


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