Persistent helps a leading US-based healthcare payer automate processes with 97% success rate, ensuring faster claims adjudication and grievance redressal.
One of the largest healthcare payers in the US, with 1.5 million members and 4,000 employees, prided itself on its member-centricity. However, as operations scaled, employees had to sift through thousands of faxed documents, manually navigate and coordinate handoffs across multiple systems. Manual operations also widened the margin for error. This significantly impacted internal capabilities by tying specialist teams to data entry and rework, causing delays and erosion of member trust.
As operations became riddled with red tape, the client turned to Persistent to overhaul the system.
Gordian ‘Operational’ Knots
The client realized manual, multi-system handoffs, especially in member-facing functions, were bottlenecks. The grievance and appeals teams struggled to resolve complaints within regulated timeframes due to manual triage and routing.
Claims adjudication suffered too, requiring analysts to navigate multiple systems to verify eligibility, update demographic and retrieve documents. The complex unstructured data, coming in via paper documents, emails and fax, was difficult to categorize and classify, leading to misrouting and additional overhead. This captured much of their bandwidth, leaving little to no room for complex cases.
For claims processors, too, the process remained largely manual, requiring them to toggle between multiple core systems and further burdening them with missing or hard-to-search information.
Although the client knew that automation was the most viable way forward, significant groundwork remained to be done. The client’s business units operated with tailored processes and KPIs, which were inconsistently tracked in spreadsheets and via email. A lack of central visibility into functional data and workflows rendered them ungovernable, leaving the room open to non-compliance risks. Any attempt to overlay automation on this fragmented landscape would, at best, create automation lakes. There was no way to benchmark the success of enterprise-wide automation initiatives; consequently, there was no way to estimate the RoI.
Building Automation as Sustainable Capability
The client partnered with Persistent to build a sustainable foundation for automation initiatives to scale and pay off.
Persistent automation and domain experts worked with the client’s business analysts and frontline teams to re-engineer processes, such as claims processing, adjudication and grievance redressal. We created a future-state roadmap based on each team’s functional requirements, identified exception paths, established common KPIs to define success metrics.
We leveraged Microsoft Power Automate to automate common workloads across cloud and desktop, supported by a reusable framework that promotes standardization and best practices. With SQL and SoapUI, we integrated data across cloud-hosted core systems, CRM and document management platforms via APIs. This sped up case progression by eliminating manual handoffs. We also automated legacy thick-client applications where APIs were limited or unavailable, reducing manual data entry and screen navigation. We packaged reusable components, such as logging, exception handling, notifications and security wrappers, within the Microsoft Power Automate framework to onboard new automations faster, at scale.
With an integrated data layer, we leveraged AI capabilities for intelligent document processing. We trained the AI model on synthetic data, generated with GenRocket, to protect personal identifiable information (PII). The AI model classifies fax documents as per usage, for example, clinical notes, appeals and grievances, using text and layout analysis. It also categorizes grievances by type, severity and line of business, automatically routing high-priority and time-sensitive cases to the appropriate queues. Human-in-the-loop review was built into the design: where classification confidence fell below a defined threshold, cases were surfaced to operations teams for validation, with corrections fed back to improve future performance.
To strengthen governance, we established an automation factory, powered by a centralized Automation Kit. This factory standardizes idea intake, prioritization, delivery and value tracking, which reduce duplicate automation efforts, accelerating time to production and improving predictability.
As a result, teams moved from ad hoc bots to a repeatable pipeline, enabling faster automation rollouts, clearer ownership, consistent KPI tracking (reduction in case handling time, number of exceptions handed over to human agents, FTE hours saved etc.) and sustained improvements in turnaround times, accuracy and regulatory adherence across departments.
Persistent Powers 97% Automation Success, 4,000+ Hours Freed
The automation initiative, co-driven by Persistent, delivered measurable gains in speed, reliability and scalability. It freed capacity for higher-value work while improving the member experience. The client:
- Achieved a 97% automation success rate in production, improving stability and confidence in scaled automation
- Improved efficiency by 66% across the targeted processes, reducing operational errors while increasing productivity
- Saved 4,000+ FTE hours annually through 25 automation solutions, enabling teams to redirect effort toward higher-value work (e.g., complex case review and proactive member outreach)
- Improved compliance with faster grievance and appeal intake and routing times
