USA’s Leading TPA Achieves 130% Increase in Auto Adjudication Rates with 50% Cost Savings   USA’s Leading TPA Achieves 130% Increase in Auto Adjudication Rates with 50% Cost Savings  

USA’s Leading TPA Achieves 130% Increase in Auto Adjudication Rates with 50% Cost Savings  

An Hexaware solution to convert legacy chaos to operational excellence


In the ever-evolving landscape of healthcare administration, our client is a prominent third-party administrator (TPA) in the USA. For over a century, the client has been dedicated to empowering individuals and businesses through their specialized offerings, including self-funded health benefits, voluntary benefits, and health and fitness management.  


Over the years, our client, a giant in healthcare administration services, has grown through acquisitions, bringing various third-party administrators into their fold. As a result, they found themselves managing a complex web of legacy systems that hindered their ability to develop a unified culture and deliver a consistent customer experience. The challenges were apparent, and their desire for a single core system was fueled by the need for transformation.  

The client sought to modernize its operations and bring together a multitude of acquired entities into a cohesive, unified claims processing system.  

The client’s vision: 

  • Optimize claims processing operations 
  • Harness the power of automation to overcome operational inefficiencies, reduce costs, and gain competitive advantage  
  • Transform future digital engagement initiatives and adopt analytics 


Hexaware, as a trusted partner, embarked on an extraordinary journey to revamp the customer’s complex legacy system, which included over seven separate applications handling different aspects of their business.  

The goal was to consolidate these disparate systems into a new, cutting-edge commercial off-the-shelf (COTS) claims processing system. Hexaware’s approach was nothing short of remarkable: 

Driving Value through Digitalization: A systematic roadmap was developed to retire the outdated applications. Proprietary accelerators played a pivotal role in significantly reducing migration time and effort. Hexaware consolidated the customer’s four complex benefits administration systems into a unified platform. An integrated data warehouse was designed to collect, store, and analyze data from various sources, including the core claims adjudication system, external systems like customer portal, billing, flex, and other interfaces enhancing the decision-making process. Additionally, modules were developed for accounting, billing, cash application, commissions, broker maintenance and funding on client’s in-house finance and billing platforms to streamline various financial aspects, reducing manual effort. 

Proactive Automation-led Transformation: Hexaware introduced a self-service Electronic Data Interchange (EDI) framework for automating data exchange processes. They used tools for impact and metadata analysis, automating code review, and creating an intuitive self-service reporting portal. This allowed the customer to generate multiple reports and access an enriched dashboard effortlessly. End-to-end testing was automated to validate outbound files and reports, further enhancing efficiency. 

RPA-enabled End-to-End BPS Support: Hexaware’s Business Process Services team provided comprehensive support for RPA-enabled claims management, from mailroom scanning to data entry, pre-processing, eligibility checks, and adjudication handling. An effective operating model was established, ensuring seamless scaling of operations and business continuity through a multi-location delivery strategy.  


With more than 5 million claims processed annually, totaling over $3 billion in payments, Hexaware achieved an accuracy rate of over 99.5%. 


The results of this transformative partnership were astounding. The customer successfully transitioned from their legacy systems to a new core claims processing system. Significant cost reductions and efficiency improvements were realized across various functions: 

  • 130% increase in auto adjudication rates  
  • 99.5% operational accuracy  
  • 50% reduction in overall claims operational costs marked a substantial financial gain. 
  • 30% reduction in manual effort, streamlining operations 


Hexaware’s digital transformation initiative revolutionized a US TPA’s operations, optimizing claims processing, reducing costs, and enhancing efficiency. The journey led to remarkable results, including a 130% increase in auto adjudication rates, 50% savings in operational costs, and a 30% reduction in manual effort, demonstrating the power of seamless digital transformation. 

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Every outcome starts with a conversation