The challenge
PacificSource is a not-for-profit health payer operating in the Pacific Northwest of the United States that serves members through highly regulated lines of business. Due to a manual process for claims transactions that was slow and resource-intensive, the payer found it difficult to keep up with increasingly fluid changes among members, plans and providers. To pinpoint where issues were arising, PacificSource documented the time and labor expenses for four transactions—adjustments, Medicaid below-the-line (BTL) claims, duplicate claims and Coordination of Benefits (COB). The estimated cost for 29 full-time employees to process these four transaction types was nearly $1.8 million per year. PacificSource required a solution that could adapt quickly to frequent regulatory updates and contain processing costs, while enabling the company to deliver high-quality experiences to members, providers and state regulators.