The Situation
A national leader in third party claims management, this organization plays a crucial role in overseeing bill review and appeals for numerous outside vendors on behalf of its clients. With a daily influx of large volumes of invoices across various vendor platforms, the organization's success hinges on its ability to maintain exceptional levels of efficiency, accuracy, and compliance. Meeting the diverse and specific requirements of each vendor platform (e.g. Legal X, T360, and Legal Xchange) is essential to fulfilling client expectations and upholding their reputation as a trusted industry leader.
The Challenge
Before intelligent automation, the bill review process was a significant operational hurdle. Teams were bogged down by manual, time-intensive tasks, including pulling daily reports, identifying invoices for submission, meticulously preparing case files, and manually uploading them to individual vendor portals. The process also required constant, daily status checks. A particularly challenging pain point was the handling of invoices with reductions, which demanded a detailed, line-by-line review to determine if an appeal was warranted. This repetitive work not only created substantial operational bottlenecks and increased the risk of human error but also prevented the team from focusing on more complex, strategic tasks. The lack of automation limited their ability to scale and threatened to impede their overall growth.
The Solution
Roots addressed these significant challenges by implementing an AI Agent that seamlessly managed the entire insurance bill review process from beginning to end across all vendor platforms. Key capabilities of the Roots’ AI Agent included intelligently extracting necessary data from invoices, automatically generating the required files, and seamlessly submitting them through the correct vendor portals. The AI Agent was also configured to retrieve and analyze invoice decisions, automatically detecting deductions and processing appeals based on predefined business rules. This approach fully automated appeals when the criteria were met, only routing complex exceptions to human staff for review, and captured a complete transaction history to ensure full compliance and client reporting.
This implementation transformed a manual, error-prone workflow into a highly efficient, automated process. It returned significant capacity to the team, enabling faster turnaround times for clients and allowing staff to dedicate their expertise to strategic, high-value work.
The Impact
The TPA has seen a significant improvement in bill processing activities across their clients:- Increased Straight Through Processing of Bills: 17,000+ invoice submissions processed in 12 months at nearly 90% automation.
- Improved Bill Review Compliance: Automatically completed 24,000+ status checks (e.g. identifying invoice decisions, detecting and reviewing deductions made) in 12 months covering 90% of status check activities.
- Fully Automated Appeals: Able to fully automate a process that once required a lot of manual intervention.
- Added Team Capacity: Returned significant capacity returned to the team, enabling faster turnaround times.
Conclusion
Ultimately, partnering with Roots transformed a historically manual process into an efficient, automated workflow. The national claims processing leader not only improved key operational metrics but also successfully unlocked a significant portion of its workforce's capacity. By freeing the team from tedious, repetitive work, the company empowered its human experts to focus on complex tasks, directly supporting its long-term goals for profitability and strategic growth.