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Case study

The challenge

Our healthcare client serving over 30,000 members in a midwestern US state, uses multidisciplinary care coordination to address the social determinants of health. Because our client was using an older version of its core platform, it required custom-coded workarounds and high levels of manual claims processing for several core administrative functions. These challenges led to low first-pass resolution rates, poor auto-adjudication rates, increased errors, delayed and inaccurate provider payments and ultimately higher costs per claim. Operating costs increased, in part because of the need to maintain the enhancements and customizations that were handled in house. As the platform version support period was ending, it put business-critical processes in a precarious situation.

Our approach

After conducting a joint evaluation, we collaborated with the client to evolve the BPaaS delivery model, which we also managed. This was accomplished through work sessions and leadership calls coordinated by our service delivery team. The client was migrated in stages to the current version of Facets. We determined the root causes for inaccurate claims processing, claims denials and approvals, and provider reimbursement delays and errors. After evaluating current auto-adjudication rates, process effectiveness and overall platform capabilities, we identified performance gaps and developed tactics to address these issues.

We implemented processes to auto-adjudicate claims of higher complexity to the greatest extent possible. Our approach increased auto-adjudication rates and payment accuracy, improving provider and member satisfaction. Working alongside the client’s operations team, we converted 142 provider agreements from Facets into TriZetto® NetworX Pricer®, to eliminate errors in contract configuration and automate accurate claims pricing. Improving that functionality increased automatic adjudication and processing of complex pricing methodologies.

Leveraging modern technologies to improve operating efficiencies and costs

By evolving the client’s BPaaS delivery model, we modernized the technology landscape to immediately improve operating efficiencies and costs. With the new systems, processes and integrated software, first-pass resolution rates improved by almost 88% and auto-adjudication rates improved by 95.6%. Our efforts surpassed the 98% goal set for claims accuracy. As a result of the new enhancements, the client also gained scalable capabilities for its future business and technology needs.

95.6% improvement

in auto-adjudication rates

~88% improvement

in first-pass resolution rates


in claims processing accuracy and consistency