e5 Improves Medical Claims Processing

A healthcare payer introduces e5 and dramatically improves medical claims processing.

Within 8 months, service levels associated with medical claims processing jumped from 5% to 94%… and 10% of back office resources were redeployed as the call center inbound workload was reduced because there were fewer calls to answer.


1. Business Situation

A prominent health insurer implemented a proprietary imaging & workflow solution to improve medical claims processing and customer service. Unfortunately the reverse happened.

Lack of processor productivity, poor service level visibility coupled with poor system performance reduced their ability to achieve service levels consistently. The result was an explosion in calls to their contact center from annoyed members querying claim payments which resulted in very frustrated staff.

With just 5% of its workflow being completed within agreed service times, the insurer was facing a ticking time bomb before customer dissatisfaction erupted.

High volume, time sensitive, manually entered work – such as in claims management environments – has the potential to be a genuine pain point for an organization.

Failure in achieving service levels increases demand on the call center environment with irate customers looking for explanations for claims not being processed on time. And ultimately, irate customers lead to the competition snatching the business.


Work Completed within SLA from two weeks prior, and after 2 weeks of using e5 and after 2 weeks of using e5’s Automated Work Allocation.

2. Solution

The solution was to replace the system with e5 Workflow, migrating all existing claims and imaging data across to the new e5/SharePoint platform.

The Automated Work Allocation capability of e5 Workflow is designed to help manage resources and their productivity, to make sure the right resource is doing the right type of work at the right time, while also improving workload management. Central to the solution is the ability to manage the end-to-end cycle, while making certain that a promise to have a piece of work done on time is done on time. Secondly, e5 addresses the issue of compliance. Work follows set patterns with controls determined by e5 Workflow.

As soon as the data was migrated to e5, it became clear why there was an explosion in customer calls. The e5 dashboard showed that Service Levels (SLA’s) were being achieved only 5% of the time.

e5 Automated Work Allocation started delivering results by delivering the oldest SLA items first. Within 2 weeks, the SLA achievement for medical claims processing passed the 30% mark, within 8 months it reached 94% and then 98% within a year.


After 8 months, a consistent SLA of 94% was achieved. A year later the service level achievements are excellent ranging between 94% and 98% on time completion.

3. Benefits

Not only was the health payer processing more work with less people, but the number of annoyed member calls to the contact center dropped sharply.

Within 8 months of going live our client was able to redeploy 10% of their back-office resources into new value-generating contact center roles.

Products and Services used:

  • e5 Workflow
  • Microsoft SharePoint
  • Third Party scanning software

Visit other resources on the Medical Claims Processing Sitemap