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Overview
The Claims Adjudication project for a leading health plan went live in April 2024, handling claims adjudication responsibilities.
The project experienced challenges in maintaining Procedural and Financial Accuracy as per Service Level Agreement (SLA) benchmarks, especially in the initial months post go-live.
This case study documents operational improvements achieved through strategic Quality Assurance (QA) interventions and a macro-based pricing tool.
Challenge
- Procedural Accuracy dropped below threshold in April–September 2024 and again in January 2025 and February 2025.
- Financial Accuracy fell short in August–October 2024 and December 2024.
- A primary concern was error-prone pricing decisions, unclear query resolutions, and delayed knowledge dissemination, which led to an increase in audit errors.
Root Cause Analysis
- Frequent pricing-related miscalculations
- High dependency on manual cross-referencing of guidelines
- Lack of a centralized repository for client clarifications
- Delays in communicating Standard Operating Procedure (SOP) and guideline updates
- Inefficient feedback cycle on audit errors
Objective
To achieve accuracy improvement from March 2025 onward through strategic Quality Assurance (QA) interventions and the implementation of a macro-based pricing tool.
Solution
Strategic Interventions
- Error-Based Feedback Sessions: Weekly analysis of audit findings to educate the team on recurring issues.
- Refresher Training: Monthly sessions focusing on SOP updates and pricing rules.
- Real-Time Feedback: Instant feedback loop for audit errors to encourage immediate course correction.
- Weekly Query Calls with Client: Regular meetings to clarify open queries and align on complex scenarios.
- Query and Update Tracker: Centralized tracker accessible by all team members for real-time updates.
- Pricing Tool (Macro-based): Introduced in February 2025 and implemented in March 2025, automating pricing validation to reduce manual judgment errors.
Impact
A marked improvement in both Procedural and Financial Accuracy was observed from March 2025 onward, directly attributed to the interventions, primarily the Pricing Tool.
Error Count Trend
- Dec 2024: 9
- Jan 2025: 20
- Feb 2025: 8
- Mar 2025: 4
- Apr 2025: 1
- May 2025: 3
Monthly Accuracy and Total Errors
| Month | Procedural Accuracy | Financial Accuracy | Total Errors |
|---|---|---|---|
| Oct 2024 | 98.58% | 98.37% | 46 |
| Nov 2024 | 98.17% | 99.37% | 48 |
| Dec 2024 | 98.31% | 97.18% | 44 |
| Jan 2025 | 97.90% | 99.11% | 143 |
| Feb 2025 | 97.80% | 99.33% | 105 |
| Mar 2025 | 99.15% | 99.81% | 30 |
| Apr 2025 | 99.23% | 99.69% | 44 |
| May 2025 | 97.90% | 99.87% | 114 |
| Jun 2025 | 98.94% | 99.69% | 89 |
Additional data from SME: High-volume audit months included May 2025 (4,088 claims audited) and June 2025 (6,297 claims audited).
Key Observations
- Accuracy improved significantly from March 2025 onward.
- Procedural errors reduced by over 70% between January and March 2025.
- Financial Accuracy consistently remained above 99% post-intervention.
- High-volume audit months like May 2025 and June 2025 still showed strong compliance due to sustained controls.
Conclusion
The Claims project underlines the impact of structured quality interventions, client collaboration, and targeted technology enablement.
The macro-based Pricing Tool addressed a significant root cause: manual pricing misjudgments.
Continuous monitoring, transparent communication, and a mature QA process drove measurable results in a short period.
