Transforming Claims Processing: $150M+ Recovery Through AI-Powered Data Mining

The Challenge

In 2020, a leading national health plan approached Machinify with a critical question: Could we identify recovery opportunities beyond their existing $100 PMPY savings? Despite having established payment integrity processes, they recognized the potential for AI-powered data mining to uncover hidden inefficiencies and drive unprecedented cost recovery.

The Approach

Machinify deployed a comprehensive AI-first strategy over three years, implementing more than 130 systems to provide a comprehensive second-pass review of each claim’s adjudicated payment. Our approach focused on teaching AI the rules of healthcare—policies, edits, contracts—and automatically building granular, accurate enforcement to increase findings, automate resolution and enable proactive error detection. 

"The AI wasn't just processing claims faster—it was learning about the claims that were getting fixed retroactively and started fixing them earlier in the cycle."

The Results

By 2024, our AI platform achieved remarkable transformation: $150M+ in incremental recoveries, equating to over $20 PMPY in savings for the plan. 86% of cases could be processed automatically with unprecedented accuracy, eliminating costs traditionally associated with the reviews, allowing upstream migration of savings, and initiating broader claim reprocessing automation across the plan. 

Key Transformation Insights: 

• Process Reimagination: Transformative AI requires rebuilding workflows from the ground up with active human expert collaboration. 

• Left-Shift Strategy: AI speed and scale enable earlier intervention, finding opportunities to prevent errors before they occur. 

• Economic Optimization: Success metrics reflecting future economics drive continuous improvement and value maximization. 

• Infrastructure Investment: Robust software and data infrastructure unlock exponential value from AI capabilities.