Claims Adjustments with Pega Robotic Automation

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This payer, like so many other health insurance companies, was burdened with complex procedures built around fragile, aging legacy systems. The cost of modifying the core systems was prohibitive and they lacked the industry resources to build a new appeals system. By implementing robotic automation, they were able to rapidly build and deploy process automation solutions, without modifying any of their current systems. The robotic automations were designed and built to emulate the exact processes followed by claim examiners, providing a positive ROI in the first year of implementation.

Business Goals

• Streamline business processes for claim processors without code modifications
• Integrate multiple legacy applications on each claim processor’s desktop
• Build an application bar to automate routine tasks required to settle appeals

Results

• Increased claims automation
• Increased settlement quality
• Reduction in processing labor and costs
• Reduced claim processing expenses