Claims Adjudication Process Improvement Case Study

This case study outlines the operational challenges faced by a nonprofit regional health system in managing its claims adjudication processes. The organization operated with a heavily manual and fragmented managed services organization (MSO), leading to inefficiencies and vulnerabilities in critical workflows. The study details a six-week assessment conducted by Impact Advisors aimed at identifying near-term value improvement opportunities while preparing for a long-term transformation with the implementation of Epic Tapestry. Key challenges included data disparity and differing workflow perspectives, which were addressed through structured interviews and data analysis. The assessment identified four critical areas for operational improvement: vendor rationalization, redesign of the forced payment process, a paper reduction initiative, and modernization of the contract management system. These initiatives are projected to deliver a significant return on investment, enhancing the organization's operational foundation and readiness for future changes.