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Claims leakage and error reduction
Processing-time reduction
Payout accuracy
A regional insurance provider was processing high volumes of claims across fragmented legacy systems, manual adjudication queues, and inconsistent policy and claims data. Claims teams had to reconcile coverage rules, member information, claim details, and payment history across disconnected workflows before decisions could move forward.
The problem was that adjudication depended too heavily on manual validation and post-review correction. Routine claims took 5–7 days to process, exceptions were not consistently detected early, and payment decisions varied across teams because policy rules and claims data were not standardized at the point of review.
The consequence was both financial and strategic. Claims leakage and errors reduced payout accuracy, slower settlements weakened customer trust, and manual workflows slowed the organization’s digital modernization agenda. Executives needed a faster claims decisioning layer that could reduce leakage, strengthen compliance, and support more predictable operations.
Novacis Digital implemented Claims Hyper-Adjudication,an AI-powered claims decisioning solution for healthcare payor operations. Itconsolidates policy, claims, and coverage data into a governed decisioningworkflow that helps teams adjudicate routine claims faster and identifyexceptions earlier.
The core mechanism combines AI-driven data standardization,claims validation, rule interpretation, anomaly detection, and exceptionescalation. Claims are evaluated against policy conditions and payment controlsbefore payout, reducing the rework and disputes that often appear after manualadjudication.
Thedifferentiator is end-to-end claims decision control, not simple taskautomation. Role-based routing, reviewer checkpoints, decision traceability,and audit-ready evidence support compliant execution at scale. This shiftsthe operating model from delayed manual reconciliation to governed claimsdecisioning.
Claims Adjudication Capabilities
Payment Integrity Features
Deployment began with a 6-week pilot across priority claims queues where delayed payouts, rework, and manual validation created the greatest operational friction. Novacis Digital then expanded the solution into broader claims decisioning workflows over a 90-day scale-up window, supporting routine adjudication, exception review, payment integrity, and compliance reporting.
Early wins included controlled processing of routine claims in hours, stronger anomaly detection before payout, and better visibility into decision history for supervisors and auditors. These gains directly addressed the provider’s core challenge: reducing leakage and errors while accelerating claims settlement without weakening governance.
Reduced claims leakage and errors by 40%, improving payment integrity and reducing avoidable payout loss across adjudication workflows.
Cut claims processing time by 78%, moving routine claims from 5–7 days to <24 hours, with many claims completed in 2–6 hours.
Improved customer settlement cycles by 60%, supporting faster payouts and stronger trust in the provider’s claims experience.
Reached 92% payout accuracy, reducing rework, disputes, and inconsistent claim decisions.
Improved customer satisfaction by 25%, reflecting faster settlement, fewer disputes, and more predictable claims communication.
