Case Study: Multi-State Medicaid and Medicare Insurer achieves 16-point improvement in claims auto-adjudication and major cost and efficiency gains with Pegasystems' Pega Claims Repair

Improving Auto-adjudication Rates Driving Claims Accuracy and Efficiency of Legacy Systems

A high-growth Medicaid and Medicare insurer serving nearly 3 million members across 13 states faced unsustainably low auto-adjudication rates and high manual claims-processing costs. Replacing its legacy core administration system was impractical, yet improving automation, accuracy and scalability was critical—each 1% lift in auto-adjudication promised the equivalent of five claims analysts saved and up to $240,000/year in interest savings.

The insurer deployed Pega Claims Repair as an agile, non-disruptive layer around its core system, quickly releasing a dozen-plus claim edits (duplicates, timely filing, authorizations, DRG pricing, etc.). Over two years auto-adjudication improved by 16 points, processing scalability rose ~50%, duplicate pends fell 66%, no-authorization pends were nearly eliminated, and the gains delivered annual savings equivalent to roughly 90 claims examiners while reducing financial risk.