Industry: HEALTHCARE
Department: FINANCE
Process: CLAIMS PROCESSING
50%
reduction in TAT
₹1 crore
in outstanding claims recovered
Minimal
human intervention
Client Overview
Max Healthcare is one of India’s leading healthcare service providers, operating 17 healthcare facilities across the country. The organization handles a high volume of insurance claims submitted through multiple TPAs (Third-Party Administrators), each using different document formats. Accurate and timely claim processing is essential to ensure seamless patient experience and steady revenue flow.
The Challenge
Max Healthcare received insurance claims data from 25 TPAs, each using a different format—ranging from emails and scanned images to PDFs and Excel files. The manual claims processing approach required significant time and effort, creating bottlenecks in reimbursement cycles and reducing overall financial efficiency.
Key pain points
- High processing time: Manual review and entry of 25+ TPA claim formats
- Lack of standardisation: 38 different document types handled manually
- Slow settlements: Delayed claim submission led to backlogs and pending payments
- Risk of errors: Manual data entry increases the chances of inaccuracies
- Low visibility: No real-time tracking of claim status or mismatches
- Resource constraints: The existing team could not scale with growing volumes
The Solution
RPATech deployed an intelligent software bot that automated end-to-end claims processing. The bot works like a digital employee, logging into systems, extracting data, validating entries, and preparing submissions, all without or with less human intervention.
Key aspects of the solution
1. Claims Data Extraction & Validation
- Automated download of claim documents from emails across 25 TPAs
- Extracts structured data using intelligent document processing (OCR + rules)
- Validates claim entries against predefined rules to check for completeness and accuracy
- Converts data into standardised formats for upload
2. Claims Upload & Reconciliation
- The bot logs into the claims management system and submits standardised claim files.
- Performs real-time reconciliation with existing records to identify duplicates or discrepancies
- Exception handling triggers alerts for human review when needed
3. Report Generation & Alerts
- Generates daily reports summarising claims submitted, matched, pending, or errored
- Sends alerts to finance and operations teams for unresolved issues
- Maintains a complete audit trail of all actions performed for compliance
Results
KPI | Pre-Automation | Post-Automation |
Claim Submission Cycle | Manual across 25 TPA formats | Fully automated claims intake |
Human Involvement | 100% manual processing | Minimal—only for flagged exceptions |
Turnaround Time | Several days per batch | 50% reduction in processing time |
Claims Recovery | Backlogs due to missed/delayed claims | ₹1 crore recovered in outstanding claims |
Accuracy & Compliance | Prone to manual errors | 100% consistency through validation |
Visibility & Reporting | Limited tracking and audit trail | Real-time dashboards and audit logs |
The Outcomes
- ₹1 crore in recovered claims – Eliminated backlog and ensured timely submission
- 50% faster processing – Reduced turnaround time with automation
- Zero data-entry errors – Automated validation improved accuracy
- Real-time visibility – Transparent reporting enhanced financial planning
- Scalable operations – Can now handle increased volume without hiring more staff
