The Claims adjudication project for a leading health plan went live in April 2024, handling claims adjudication responsibilities. The project experienced challenges in maintaining Procedural and Financial Accuracy as per Service Level Agreement (SLA) benchmarks, especially in the initial months post go-live.
A documented operational improvement through strategic Quality Assurance (QA) and a macro-based pricing tool.
Procedural Accuracy dropped below threshold in April-September 2024 and again in January 2025 and February 2025.
Financial Accuracy fell short in August-October 2024 and December 2024.
A primary concern was the error-prone pricing decisions, unclear query resolutions, and delayed knowledge dissemination, which led to an increase in audit errors.
To achieve accuracy improvement from March 2025 onward through strategic Quality Assurance (QA) interventions and the implementation of a macro-based pricing tool.
A marked improvement in both Procedural and Financial Accuracy was observed from March 2025 onward, directly attributed to the interventions, primarily the Pricing Tool.
Error Count Trend
Monthly Accuracy and Total Errors
| Month | Procedural Accuracy | Financial Accuracy | Total Errors |
|---|---|---|---|
| Oct 2024 | 98.58% | 98.37% | 46 |
| Nov 2024 | 98.17% | 99.37% | 48 |
| Dec 2024 | 98.31% | 97.18% | 44 |
| Jan 2025 | 97.90% | 99.11% | 143 |
| Feb 2025 | 97.80% | 99.33% | 105 |
| Mar 2025 | 99.15% | 99.81% | 30 |
| Apr 2025 | 99.23% | 99.69% | 44 |
| May 2025 | 97.90% | 99.87% | 114 |
| Jun 2025 | 98.94% | 99.69% | 89 |
Additional data from SME: High-volume audit months included May 2025 (4,088 claims audited) and June 2025 (6,297 claims audited).
Key Observations
Conclusion:
The Claims project underlines the impact of structured quality interventions, client collaboration, and targeted technology enablement. The macro-based Pricing Tool addressed a significant root cause: manual pricing misjudgments. Continuous monitoring, transparent communication, and a mature QA process drove measurable results in a short period.
