Healthcare payers are facing increasing margin pressures despite revenue growth, as healthcare costs continue to rise. In order to stay ahead of industry trends and outperform competitors, payers must introduce new efficiencies into key operations such as claims processing.
Traditional claims audit processes have been reactive and labor-intensive, making them insufficient for today’s complex healthcare payments ecosystem. Mistakes in claims processing can result in significant financial losses, highlighting the urgent need for accuracy and compliance.
Leading payers are now revolutionizing their claims audits by leveraging innovative technologies such as robotic process automation, advanced workflow management, analytics, and AI/GenAI. These technologies drive business value by minimizing errors and reducing the need for post-payment audits.
Current challenges in claims auditing for payers include manual processes that are not scalable. With large health plans processing millions of claims annually, audit volumes can overwhelm teams, compromising quality and increasing error rates. Manual audits are also time-consuming and reactive, often leading to delayed claims processing and increased operational costs.
Regulatory complexity further complicates the claims auditing process, with evolving federal and state mandates adding layers of difficulty. Medicare and Medicaid alone made $100 billion in improper payments in 2023, primarily due to administrative errors. Fraud, waste, and abuse also remain persistent issues, costing the U.S. healthcare system billions annually.
By transforming claims auditing with automation and AI, payers can standardize processes, catch errors earlier, and identify areas for continuous improvement. Automating repetitive tasks saves time and minimizes human error, while advanced analytics provide insights for enhancing operations.
Payers can use technology to identify process bottlenecks, streamline audit processes, improve data integrity, implement real-time monitoring, and utilize predictive analytics. AI agents can assist auditors by suggesting codes based on clinical documentation, while training programs can enhance auditor expertise and improve audit quality.
Sutherland offers a comprehensive approach to digital transformation for payers, starting with an Intelligent Automation Operating Model that automates manual processes within a secure framework. By implementing workflow management tools, smart analytics, and next-generation AI tools, payers can drive operational improvements, save costs, and improve accuracy in claims processing.
Infusing automated technologies and continuous-improvement strategies into claims audit processes can lead to significant cost savings, improved accuracy, and simplified compliance. By providing faster and more accurate claims processing, payers can enhance member experiences and strengthen provider relationships.
To learn more about how Sutherland is helping payers drive operational improvements, connect with a member of their team today.
