At a glance
Industry
Healthcare
Location
North America
Challenge
Manual triage of appeals & grievances led to delays, inconsistencies and significant staffing costs.
Products and services
Gen AI-powered appeals management solution
Success Highlights
- $1.4M saved over 3 years by automating A&G case triage
- Rapid reduction in team size from 20 to 5 in just 7 months
- 90% Accuracy rate in the case triaging automation process
Our approach
After our successful proposal, Cognizant embarked on a transformative journey to enhance the client’s appeals and grievances process. We brought our experience in applying AI and cloud technologies to address complex challenges in the healthcare sector, ultimately aiming to improve outcomes and operational efficiency.
Cognizant developed a appeals & grievances categorization assistant, powered by generative AI, designed to streamline Complaints, Appeals, and Grievances (A&G) triage process and enhance the accuracy of the case categorization process.
The solution incorporated these elements:
- Intent and entity recognition: The assistant leverages advanced AI to automatically understand the intent behind each appeal. It extracts relevant information from various document types, whether structured (like forms and databases) or unstructured (such as documents with images, emails and handwritten notes). This reduces the need for manual interpretation, ensuring that all necessary information is accurately captured and processed.
- Dynamic knowledge mapping: The system maps identified entities and concepts to relevant regulations, policies and medical records. This provides a comprehensive context for decision-making, ensuring that each case is evaluated with all pertinent information at hand. It enhances the accuracy and consistency of case categorization, aligning decisions with current regulations and policies.
- Decision support: Based on the extracted information and contextual knowledge, the assistant predicts the category, subcategory, subtype, priority and case partner; performs a duplicate check; and provides a summary of each case. This predictive capability helps in quickly and accurately classifying cases. It streamlines the process, reduces administrative burden and ensures timely resolution of appeals and grievances.
Business outcomes
This forward-thinking solution brought our client these results:
- $1.4 million Cost savings over 3-yr period due to Rapid FTE reduction because of automated G&A case triaging process
- Rapid FTE reduction from current 20 FTEs involved in the case triage process to 5 FTEs over a period of 7 months because of automation
- 90% Accuracy rate in the case triaging automation process
By implementing the gen AI-powered assistant, Cognizant transformed the client’s appeals and grievances process, making it more efficient, accurate and responsive.