Case Study

Claims automation saves $1.5 million annually for leading payer



A leading payer achieved $1.5 million through HGS’s claims automation, with 7 million claims processed with an efficiency gain of 22%

Client background

The client is one of the largest health insurance plans in the U.S.

Business challenge

When a top five payer was undergoing claims transformation, they turned to HGS for identification of significant opportunity for claims prework efficiencies. This client needed faster turnaround time (an essential Star rating metric) by validating claims prework fields to prevent payments from going to the wrong provider, with member benefits aligned for correct payouts.

The solution

HGS collaborated with the client’s newly formed unit charged with launching RPA companywide. HGS worked with the client to identify and select the right opportunities, at both prework in commercial claims and pend codes in Medicare Claims for automation.

HGS’s team of 10 design and development resources identified and validated processes and supported both prework and pend code architecture design, development, implementation, testing, and documentation. The scope of RPA, leveraging 25 bots, addressed both medical and hospital claims at prework, with initial steps for solving an edit in manual adjudication to validate provider, subscriber, member, billing, coordination of benefits, and determination of content cleanliness. All steps were rule-based.

For the pend codes process, inefficiencies in payment were identified without referral authorization, for a downstream impact on rework and calls. By bucketing the claims and automating validation, duplicate logic/follow-up logics could be avoided and more accurate, quicker identification of claims for payment were released, for significant end-to-end process improvements on client payments.

The solution helped drive success in these areas:

  • Achieved downstream reduction in rework
  • Improved prework accuracy to reduce effort and amount of rework downstream
  • Shortened transaction time
  • Avoidance of CMS-related penalties related to turnaround time, which could impact Star ratings
  • Provided quality check of manually adjudicated claims


With claims troubleshooting, root causes analyses, and actionable insights, this drove significant impact on the claims lifecycle. This included:

  • $1.5 million cost savings per year
  • 7 million claims processed 
  • 22% efficiency gains, trimming 40 seconds off 3 minutes
  • 30% agents reallocated to higher-tier work
  • 10% rework reduction
  • Upstream billing error rectification recommendations

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