In the evolving healthcare landscape, payers face increasing pressure to enhance operational efficiency, reduce costs, and deliver value-based care. At the core of this transformation lies the need to modernize claims processing, traditionally one of the most resource-intensive and error-prone functions in healthcare administration. As value-based models demand faster, more accurate reimbursement and tighter integration with clinical and financial data, legacy claims processes often fall short. The imperative is clear: to remain competitive and compliant, payers must embrace intelligent automation to transform how they manage claims.

The Challenges: Manual Workflows, High Error Rates, and Delayed Reimbursements

For decades, claims processing has relied heavily on manual workflows that are not only labor-intensive but also susceptible to human error. These inefficiencies lead to costly mistakes, such as duplicate payments, incorrect denials, and delayed reimbursements. In a system where turnaround time directly impacts provider relationships and member satisfaction, such delays can no longer be tolerated.

Additionally, regulatory complexities and shifting payer-provider dynamics further strain legacy systems. As the volume and complexity of claims grow, so do the administrative costs. This creates a critical need for a solution that improves accuracy, speeds up adjudication, and ensures regulatory compliance, without increasing overhead.

The Mphasis Approach: AI-Driven, End-to-End Transformation

Recognizing these challenges, Mphasis has pioneered a comprehensive, intelligent approach to claims transformation. By integrating advanced technologies such as Artificial Intelligence (AI), Robotic Process Automation (RPA), and proprietary platforms, Mphasis delivers an agile, scalable framework for modernizing payer operations.

AI and RPA for Smart Adjudication

At the heart of Mphasis’ strategy is the integration of AI and RPA into the claims adjudication process. AI models analyze structured and unstructured data to identify inconsistencies, predict outcomes, and flag potentially fraudulent claims before they are processed. RPA bots handle repetitive tasks such as data entry, validation, and routing, significantly reducing processing time and minimizing human error.

This intelligent combination not only accelerates the adjudication process but also ensures greater consistency and accuracy in claim evaluations, freeing up human resources to focus on more complex, value-added tasks.

Leveraging Javelina® for Seamless Data Flow and Compliance

Mphasis enhances this automation ecosystem with the integration of the Javelina® platform, a next-generation core administrative processing system designed specifically for healthcare payers. Javelina® supports real-time processing and ensures seamless interoperability across disparate systems. This robust infrastructure enables smooth data flow between claims, billing, and provider management systems while maintaining compliance with regulatory standards such as HIPAA and CMS guidelines.

Javelina’s modular design allows for customizable implementation, ensuring that each payer’s unique business rules and workflows are respected while still achieving process standardization and automation.

Front2Back™ Transformation for Holistic Optimization

To fully realize the benefits of intelligent claims processing, Mphasis applies its Front2Back™ transformation framework, a holistic approach that aligns front-end member and provider engagement with back-end operational systems. This strategy ensures that every touchpoint in the claims lifecycle, from initial intake to final reimbursement, is optimized for speed, accuracy, and user experience.

By aligning technology with business outcomes, the Front2Back™ model promotes continuous improvement and drives measurable results across the entire value chain. This approach not only improves claims performance but also enhances payer agility in adapting to regulatory changes and market demands.

Use Case: Transforming Claims Processing for a Leading Health Risk Management Firm

A prominent leader in health risk management and third-party administration of self-funded health benefit plans faced significant challenges with their high-volume, manual claims processing system. This manual approach led to slow turnaround times, decreased accuracy, and strained resources, ultimately impacting customer experience and patient health outcomes.

To address these issues, Mphasis collaborated with the client to embark on a transformational journey. Utilizing Design Thinking methodology, Mphasis analyzed and identified that 80% of the organization's claims-related processes were ripe for improvement. By applying lean principles, automation, and sourcing strategies, Mphasis revamped the client's claims processing systems.

Key interventions included the automation of two claim types—Accidental and Authorization Claims—resulting in a 70% increase in automation. Mphasis also implemented process analytics to identify root causes of delays and developed automatic routing of claims to appropriate teams. Furthermore, core administrative system changes were enabled for straight-through processing, eliminating multiple hand-offs in claims adjudication.

These combined efforts led to a streamlined, highly automated claims process, including an optimized claims information intake workflow manageable by a single person. The result was fewer repeat calls requesting information, more automation, and faster disbursements, significantly enhancing the overall customer experience.

KPIs: Quantifiable Improvements in Claims Processing Efficiency

The transformation yielded substantial business benefits, including:
• Reduced Per Claim Processing Time: Achieved a 30%–35% reduction in the time taken to process each claim.
• Improved Auto-Adjudication Rate: Over 50% improvement in auto-adjudication rate within four weeks.
• Enhanced Financial and Payment Process Quality: Reduction in errors and improved quality of financial and payment processes to 99.5%.
• Projected Cost Reduction: Anticipated 40% cost reduction over a period of three years.
• Increased Straight-Through Processing: Higher levels of straight-through processing, reducing manual interventions.
• Resource Reallocation: Freed up resources to focus on improving user and patient outcomes.
• Enhanced User Satisfaction: Ability to focus on high-value activities led to increased user satisfaction.

These KPIs underscore the effectiveness of Mphasis's approach in leveraging AI and automation to transform claims processing, resulting in improved efficiency, accuracy, and customer satisfaction.

Conclusion

As the healthcare industry continues its shift toward value-based models, payers must transform their claims operations to remain competitive and compliant. Mphasis offers a future-ready solution through the intelligent integration of AI, automation, and domain expertise. With platforms like Javelina® and frameworks like Front2Back™, Mphasis empowers payers to streamline operations, reduce costs, and deliver better outcomes for members and providers alike. With Mphasis, the future of claims processing is not just digital, it’s intelligent.

Summary

Q. What is intelligent claims transformation?
A. It's the application of AI and automation to streamline and enhance the accuracy of claims processing.
Q. How does Mphasis facilitate this transformation?
A. By leveraging platforms like Javelina® and methodologies like Front2Back™ to automate and optimize claims workflows.
Q. What benefits do payers experience?
A. Faster processing times, reduced errors, cost savings, and improved member experiences.