A leading US health insurer
Reduced claim cycle time from 14 days to 8 with AI triage and BPO+RPA hybrid delivery.
What was getting in the way.
A top-10 US health insurer was processing over 2.4 million claims monthly across five disparate legacy platforms. Manual keying errors averaged 6.8%, prior-authorisation backlogs ran 9–12 days, and member satisfaction scores sat at 56 CSAT.
The compliance team flagged audit risk from incomplete audit trails on 18% of high-value claims. Every missed SLA triggered contractual penalties with employer group clients — and the business was growing faster than its operations could keep pace.
What we deployed.
Gennexa deployed a three-layer hybrid: an AI triage model classified and auto-routed 74% of incoming claims in under 3 seconds. An RPA layer pre-filled adjudication fields from structured EDI and unstructured medical records using intelligent document processing (IDP).
A BPO pod of 120 specialist agents was equipped with copilot dashboards surfacing policy coverage, clinical guidelines, and member history in a single pane — eliminating the need to toggle across systems.
The NexaFlow orchestration engine connected all five legacy platforms via API adapters — no rip-and-replace. A real-time quality dashboard gave the VP of Operations live visibility into error rates, cycle time, and exception queues across every team.
What we measured.
Claim cycle time dropped from 14 days to 8.2 days — a 41% reduction — within 90 days of full deployment. Keying errors fell from 6.8% to 0.9%.
Prior-auth decision throughput increased 3.1× on the same headcount. Member CSAT recovered from 56 to 79 in two quarterly surveys. Audit-ready documentation was auto-generated on 100% of claims, eliminating the compliance gap entirely. The programme paid back the full deployment fee in month 7.
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