Case Study: Self-Insured Retailer

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Our client is self-insured with over 6,500 stores across 11 countries. They came to us looking for ways to automate existing manual processes that were slowing them down, reduce their reliance on bill review due to significant associated fees, and decrease their overall costs.

Where They Needed Help

  • Manual processes were overwhelming adjusters
  • Adjusters were being presented with 100% of medical bills
  • Bill review costs were incurred on 100% of medical bills
  • Bills were not being adequately screened for appropriateness

How We Helped

  • We auto-adjudicated 70% of all document types before bill review (leading to significant bill review savings)
  • Relatedness and Rarity rules identified 26% of medical charges which were presented to adjusters for possible rejection
  • 78% of system-identified, message-based rejected bills did not return for payment

Average 21% Reduction in Medical Spend


Previous Spend (100%)


Year 1 (21.4% Reduction)


Year 2 (25.5% Reduction)


Year 3 (26.6% Reduction)

Other Impacts on the Client

  • The reduction in spend increased year over year due to modifications in business rule sensitivity, our performance measures of vendors and auto-approval of certain procedure sets and providers.
  • The rarity and relatedness rules we implemented now account for 42% of message-based rejections.


This company, like so many others, was utilizing resources on functions that can easily be automated. Instead of wasting time on routine tasks, their adjusters now have a huge part of their day back to focus on closing the problematic and complex claims. They enjoy cost savings on bill review as well, since our system is able to identify bills that should never have been submitted in the first place (and may have been errantly paid). As a final result, they are seeing a significant reduction in medical spend – a number that continues to improve as we tailor our system to their growing and changing business needs.

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