Summary
We partnered with a worldwide Medical Insurance Provider to revolutionize their medical provider payment processing system, tackling a high-volume operation that manages 168,000 annual transactions with a 14% yearly growth rate. Our solution automated 80% of this workflow, dramatically reducing processing time from 16 to 4.5 minutes per transaction while cutting staffing requirements by a third. The implementation has delivered estimated annual savings of MXN $336 million by virtually eliminating costly payment errors and has transformed provider relationships through reliable, accurate payment processing.
Objectives
- Transform the manual provider payment management process handling 12,000 monthly transactions
- Eliminate payment errors causing significant financial penalties (of aprox. 100 thousand MXN)
- Reduce processing time while maintaining accuracy across diverse contractual arrangements
- Improve provider satisfaction by resolving the issues causing 1,600 annual complaints
- Optimize resource allocation by freeing staff from repetitive tasks
- Create a scalable solution to accommodate the 14% annual growth in transaction volume
Our Team
Our implementation team comprised payment processing specialists, automation engineers, and integration experts who worked directly with our client’s operations team.
Tech Stack
The solution leverages:
- Reachcore portal as the document submission interface
- Custom document processing engine for intelligent data extraction
- Business rules engine capable of processing diverse contractual arrangements
- Integration layer connecting with corresponding NZ and INFO platforms
- Exception management dashboard for human-in-the-loop handling of complex cases
Solution
Our approach addressed the inherent complexity of processing payments across 500+ healthcare providers, each with unique contractual terms:
Intelligent Document Processing
We developed a system that automatically processes the seven distinct documents (averaging seven pages each) required for each transaction. The solution extracts, validates, and cross-references critical information without manual intervention.
Contract-Adaptive Processing
The core innovation lies in our dynamic contract interpretation engine. Rather than attempting rigid standardization, we built a system that adapts to each provider’s unique terms, handling variations in payment structures, timelines, and special conditions automatically.
Multi-stage Verification
Each transaction undergoes a comprehensive verification sequence:
- Document completeness and validity check
- Contract terms application and verification
- Credit note reconciliation against primary documentation
- Payment calculation with appropriate commercial terms
- Final validation before payment authorization
Payment Execution
Once verified, the system automatically routes payments through the appropriate platform: standard transactions through NZ and individual policy payments through INFO. Hence, ensuring proper accounting and timely disbursement.
Continuous Learning
The system captures exceptions and their resolutions, continuously refining its processing logic to handle increasingly complex scenarios without human intervention.
Results
The transformation delivered exceptional results across multiple dimensions:
Operations
- Processing Efficiency: 72% reduction in handling time (from 16 to 4.5 minutes per transaction)
- Resource Optimization: Staff requirements reduced from 12 to 8 employees despite volume growth
- Scalability: System now handles 14,000 monthly transactions, up from 12,000, with capacity for continued growth
Financial Impact
- Error Reduction: Virtually eliminated payment errors that previously affected an estimated 10% of transactions
- Cost Avoidance: Estimated MXN $336 million annual savings from prevented payment penalties
- Productivity Gains: Cumulative time savings of 71,771 hours over three years, equivalent to 14 full-time positions annually
Provider Satisfaction
- Complaint Reduction: Dramatic decrease from the previous 1,600 annual provider complaints
- Relationship Improvement: Enhanced trust with the provider network through reliable, accurate payment processing
- Quality Transformation: Comprehensive improvement in both administrative efficiency and economic accuracy
Team Benefits
- Strategic Redeployment: Four team members reassigned to higher-value strategic initiatives
- Work-Life Balance: Elimination of overtime previously required for manual processing
- Retention Improvement: Reduced operational staff turnover by removing repetitive, error-prone work
This comprehensive transformation has positioned this medical insurer as an industry leader in provider payment management, creating a competitive advantage through operational excellence while delivering significant bottom-line impact.