Industry
Healthcare
Challenge
Facing persistent gaps in payment integrity, a top-10 health plan needed to strengthen its claims data mining and audit capabilities. The organization was missing recovery opportunities due to outdated, manual processes and was overly dependent on high-cost external vendors for audit work that could be brought in-house. To scale effectively, the plan required a modern solution that would empower internal teams with advanced automation, improve concept implementation speed, and deliver more impactful, accurate results across the payment lifecycle.
Results
By deploying Machinify Pay and Machinify Audit, the health plan achieved a 224% increase in DRG findings, a 57% reduction in downstream contingency fees, and an 80% reduction in concept implementation time. These outcomes enabled the plan to boost in-house recoveries, increase audit yield, and minimize administrative burdens, establishing a scalable foundation for high-value payment integrity work.
Key Product
Machinify Pay, Machinify Audit
Machinify's strength is that their NLP and large language model capabilities are advanced, so they are more efficient in reviewing and in selection. Machinify has the right strategy, and their automation capabilities are among the best that we have seen so far in the industry.
The Challenge
The health plan encountered significant obstacles with its legacy payment integrity processes. Manual rules and static review methods left gaps in post-pay data mining, resulting in missed recovery opportunities. Additionally, reliance on external vendors for audit activities incurred high contingency fees and limited the plan's internal control over payment integrity outcomes. To address rising costs and operational inefficiencies, the organization sought a scalable, automated solution to empower its own teams, accelerate implementation, and enhance both data mining and audit performance.
The Solution
After evaluating available technologies, the health plan selected Machinify Pay and Machinify Audit to modernize its payment integrity operations. Machinify Pay enabled the plan's internal teams to automate the discovery and deployment of new payment integrity concepts through continuous feedback and adaptive workflows, replacing static rule libraries. Machinify Audit provided intelligent claim selection, real-time analytics, and automated workflows, allowing auditors to identify more complex recovery opportunities and reduce dependence on external vendors. The integrated approach equipped the plan to drive higher-value work in-house, streamline processes, and improve financial outcomes.
The Results
The adoption of Machinify solutions delivered measurable improvements across the health plan's payment integrity initiatives. The organization realized a 224% increase in DRG findings, with PMPY yield rising from $14.86 to $48.14. Downstream contingency fees were reduced by 57%, and concept implementation time was cut by 80%, expediting the transition from concept discovery to production. The health plan also achieved a 64% increase in DRG hit rate, further amplifying its in-house audit effectiveness. Together, these results established a scalable, efficient model for payment integrity, reducing administrative costs and enhancing recovery performance.
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