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- AI Automate Claims Auto-Adjudication
Improved claims
auto-adjudication
from 75% to 92%
How a Provider transformed operations with AI and automation
Introduction
A leading Provider organization improved claims auto-adjudication, scaled advanced AI/ML models across care, operations, and experience, automating 7+ clinical workflows, and saved nearly $5 million annually.
Healthcare operations are complex, and for large provider organizations, scaling efficiency while ensuring care quality is no small feat. Manual, fragmented processes and limited AI adoption often stand in the way.
That’s exactly where one of the strongest regional health plans, a subsidiary of one of the largest integrated health systems in the US, found itself. Their claims Auto Adjudication Rate (AAR) was stuck at 72%, far below the industry benchmark of 95%. Manual interventions were driving up costs and creating delays in claims resolution.
They partnered with CitiusTech to unlock the power of AI/ML and automation, and to explore how far their existing infrastructure could take them.
The Challenge: Scaling adjudication without scaling cost
Despite having robust infrastructure in place, the client struggled with a fragmented adjudication process. The issues included:
- Sub-optimal AAR of 72%.
- Heavy reliance on manual adjudication, increasing administrative burden.
- Disconnected systems that couldn’t support end-to-end AI workflows.
- A need to assess feasibility of running ML pipelines using current tech stack.
The objective was clear: Use advanced AI/ML to improve adjudication accuracy, reduce manual intervention, and scale using existing platforms.
The Solution: An integrated AI/ML & automation framework for claims processing
CitiusTech designed and deployed a centralized AI/ML platform that seamlessly integrated with the client’s current infrastructure and delivered intelligent automation at scale.
Key Solution Highlights:
- Automated ML workflows for model development and training
- Feature engineering using explainable models and reusable components
- Integration with clinical and administrative systems for real-time insights
- AI-driven dashboards to track performance and drive decision-making
- End-to-end workflow automation across 7+ use cases
Business Impact: Intelligent outcomes across the care ecosystem
The impact of this transformation was felt across the enterprise, and the results were rapid and remarkable.
- Auto-Adjudication Rate improved from 75% to 92%
- ~$5 million in annual savings through reduced manual adjudication
- 7+ clinical and administrative workflows automated
- Enhanced visibility and adoption through intuitive, real-time dashboards
What began as a feasibility study evolved into an enterprise-level transformation, improving outcomes for the organization and the broader health system it supports.
Why CitiusTech: Built for healthcare. Engineered for scale.
What set this transformation apart was CitiusTech’s ability to deliver AI and automation tailored to healthcare realities. With a deep understanding of provider and payer operations, regulatory constraints, scalable architecture, and proven healthcare AI accelerators, CitiusTech delivers AI solutions that drive real business value.
From use case discovery to platform engineering and workflow automation, the solution was end-to-end and built to evolve.
