Claims Processing Automation

Processing claims 10x faster with AI-powered review

OBJECTIVES

Reduce average claim processing time by 80%+Automate document extraction and validationRoute complex claims to appropriate adjusters

PROJECT TYPE

Automation

A specialty insurance carrier processed claims manually.

Automate Your Claims

15 MIN · NO PREP REQUIRED

Python for ML and automation—Azure Document Intelligence for extraction—Custom rules engine for coverage—IBM MQ for AS/400 integration—React dashboard for adjusters—PostgreSQL for claims data warehouse—

OVERVIEW

A specialty insurance carrier processed claims manually. Each claim required 45 minutes of adjuster time—reviewing documents, validating coverage, calculating payouts. Backlogs grew. Customer satisfaction fell. We automated the routine work, achieving 91% straight-through processing and freeing adjusters for complex cases.

THE PROBLEM

The carrier specialized in small business insurance—a niche with high claim volume but relatively standardized cases. Each claim, regardless of complexity, went through the same manual process.

Adjusters spent 70% of their time on routine tasks: extracting data from documents, validating policy coverage, calculating standard payouts. Only 30% went to actual judgment work—investigating suspicious claims, negotiating settlements, handling appeals.

A 2-week backlog meant unhappy policyholders. Staff burned out from repetitive work. The carrier couldn't scale without proportionally scaling headcount—an expensive proposition in a competitive market.

CONSTRAINTS

Must comply with state insurance regulations
All automated decisions must be auditable
Cannot auto-deny—humans make all denial decisions
Must integrate with legacy IBM AS/400 policy system
Fraud detection must maintain current accuracy
Policyholders should not notice process change

DELIVERABLES

What we shipped.

FIG. 02

AI document extraction for claims forms

Automated coverage validation against policy

Payout calculation engine with state-specific rules

Routing system for complex claims

Audit trail for all automated decisions

AS/400 integration layer

Adjuster dashboard for exception handling

KEY DECISIONS

How we solved it.

FIG. 03

Full automation or human-in-the-loop?

Straight-through for simple, human for complex

Simple claims (clear documentation, standard coverage, under threshold) process automatically. Complex claims (documentation issues, coverage questions, high value) route to adjusters with AI-prepared summaries. This maximizes automation while maintaining quality.

How to integrate with AS/400?

API wrapper with nightly sync

Replacing AS/400 wasn't feasible. We built an API layer that reads/writes to AS/400 in real-time for lookups and queues updates for batch processing. This preserved the system of record while enabling modern automation.

Train one model or specialized models?

Specialized models by document type

Claims include varied documents: invoices, receipts, police reports, medical records. Specialized extraction models for each type outperformed a general model. Ensemble approach routes documents to appropriate model.

OUTCOMES