AI-powered claims modernization reduced false positives by 25%, delivering ~$3M in annual savings while accelerating audits and strengthening compliance.
- 25% reduction in false positives → ~$3M annual savings
- Faster audits and onboarding — from weeks to days
- Unified claims workflows improving staff efficiency and payer outcomes
Business Context
The insurer’s monolithic legacy claims platform created inefficiencies and compliance risks:
- Limited Scalability: Unable to keep pace with growing claim volumes.
- Fragmented Processes: Disconnected pre-pay, post-pay, audit, and recovery workflows.
- Slow Audits: Time-consuming reviews and onboarding delays.
- High Error Rates: Costly false positives in claim detection.
- Regulatory Burden: Complex CMS, Medicaid, and state-specific compliance requirements.
Solution
Forte Group partnered with the insurer to deliver a comprehensive modernization of its claims platform.
Key components included:
- Cloud-Native Microservices: Replaced monolithic legacy architecture.
- AI-Powered Review Logic: Reduced false positives and improved overpayment detection.
- Real-Time Dashboards (Studio42): Delivered actionable insights across workflows.
- Modern Tools: Integrated Replay, CoPilot, and LyricIQ for automation.
- Intuitive UI: Usable by both technical and non-technical staff.
- Enterprise-Grade Compliance: Ensured security, privacy, and uptime across CMS and Medicaid standards.
- Global Delivery Model: 30+ senior engineers in Poland dedicated to ongoing support.
Results & Value Delivered
- 25% fewer false positives in claim reviews → ~$3M annual savings
- Audit cycles accelerated from weeks to days
- Faster onboarding for new payer workflows
- Actionable real-time dashboards improving operational visibility
- Regulatory compliance strengthened across CMS, Medicaid, and state rules
- Improved scalability and integration with top U.S. health plans
- Staff freed from manual bottlenecks, enabling higher-value payer engagement
