The Customer

The customer is a U.S.-based healthcare cost containment organization supporting self-funded health plans, plan sponsors, and stop-loss carriers. Its core responsibility involves reviewing healthcare claims to identify overpayments, pricing anomalies, and compliance issues—work that directly impacts healthcare affordability and fiduciary accountability.

Each claim decision requires consistency, accuracy, and clear justification. As volumes increase, maintaining review quality while controlling operational cost becomes increasingly difficult without structured decision support.

What Triggered the Change

At the time of evaluation, the organization processed approximately 150 claims per month, with plans to scale to 300+ claims per month in the near term. The existing operating model relied heavily on manual reviews supported by rigid workflow tooling.

While functional at lower volumes, this approach introduced linear scaling challenges. Every increase in claim volume required proportional increases in reviewer effort, directly impacting turnaround time and cost per claim.

Leadership identified that continuing along this path would require staffing expansion rather than system improvement, limiting the organization’s ability to grow efficiently.

The Challenges

Manual, Resource-Intensive Reviews

All claims entered the same review queue regardless of complexity or risk profile. Low-risk and predictable claims consumed reviewer capacity that could otherwise be allocated to complex, high-impact cases.

Rigid Workflow Infrastructure

The existing workflow system lacked flexibility for nuanced, evolving decision logic. Review criteria changes required technical updates, slowing response to operational insights.

Absence of a Rule-Based Decision Layer

There was no structured mechanism to apply consistent threshold-based or policy-driven rules across claims. Even predictable outcomes relied on manual judgment.

Rising Cost Per Claim

Because review effort scaled linearly with volume, each additional claim increased operational cost, constraining sustainable growth.

Why the Previous Approach Fell Short

As claim volume grew, operational friction became increasingly visible.

Reviewers spent disproportionate time on low-risk claims with well-understood patterns. Meanwhile, complex cases competed for attention in the same queues, reducing focus and increasing turnaround times.

Business teams understood which claims should be escalated or fast-tracked, but they lacked a way to encode that knowledge directly into the system. Workflow logic lived in tooling that was difficult to evolve without engineering support.

Over time, the review process shifted from amplifying expert judgment to consuming it.

What the Customer Needed

The organization sought a solution that could:

• Automatically separate straightforward claims from complex ones
• Apply consistent, explainable decision criteria
• Enable business teams to evolve rules without engineering dependency
• Maintain complete auditability for every decision
• Comply with HIPAA and data residency requirements
• Scale claim volume without proportional cost increases

The Solution: How Nected Was Implemented

The customer implemented Nected as a centralized claims triage and decision layer, integrated into existing claims review workflows.

Automated Claims Triage

Each incoming claim is evaluated against a defined set of business rules covering cost thresholds, complexity indicators, and policy criteria. Claims that meet escalation thresholds are routed to human reviewers, while predictable claims proceed automatically.

This ensures expert judgment is applied where it creates the most value.

Centralized Rule Management

All decision criteria now live in a single rule layer, replacing fragmented logic across workflows, spreadsheets, and ad hoc processes.

Business-Owned Rule Configuration

Operations teams define, test, and refine triage rules directly using Nected’s no-code interface. Day-to-day changes no longer require engineering involvement.

Multi-Source Data Integration

Nected integrates with internal databases and external data sources, ensuring decisions are evaluated against current, reliable inputs.

Governance, Versioning, and Auditability

Every rule update is versioned and logged. Each claim decision can be traced to the exact rule set and effective date applied, supporting audits and internal reviews.

HIPAA-Compliant Deployment

Nected supports secure cloud and on-premises deployment models, enabling compliance with HIPAA and internal security requirements.

Before vs After Transformation

Quantitative Outcomes

(All metrics are customer-validated.)

• 2× claims processing capacity
  Monthly claim throughput increased from approximately 150 to 300+ without a corresponding increase in reviewer headcount. Automated triage removed low-complexity claims from manual queues, allowing the organization to handle higher volumes using the same operational footprint.
• Reduction in manual reviews
  A large portion of predictable, low-risk claims now bypass human review entirely. This reduced repetitive handling, minimized review backlogs, and allowed teams to reserve manual intervention for claims that genuinely required expert assessment.
• Lower cost per claim
  By concentrating reviewer effort on complex and high-impact cases, the organization reduced wasted effort on routine checks. This shifted the cost structure away from linear growth and improved unit economics as volume increased.

Qualitative Outcomes

• More effective use of expert judgment
  Reviewers now spend the majority of their time on nuanced claims involving pricing discrepancies, policy interpretation, or higher financial risk, rather than repetitive validation tasks.
• Faster and more predictable turnaround times
  Automated decisions reduced queue congestion and variability in processing times, resulting in more consistent turnaround for both simple and complex claims.
• Consistent and explainable decisions
  Rule-driven evaluations apply the same criteria across all claims. This improved internal consistency, reduced subjective variance, and made outcomes easier to explain to stakeholders.
• Increased compliance and audit confidence
  Every decision remains fully traceable to the rule version and inputs used, simplifying internal reviews and strengthening confidence during audits.

Why the Customer Chose Nected

The decision centered on scaling claim review operations without diluting judgment quality, transparency, or regulatory alignment.

Nected allowed the organization to translate institutional knowledge—previously held only by experienced reviewers—into explicit, governed rules that business teams could manage directly. This reduced dependence on engineering while preserving control and accountability.

Equally important was governance and auditability. Built-in versioning, effective-date handling, and execution logs ensured that every claim outcome could be explained and defended, a critical requirement in healthcare cost containment.

Deployment flexibility also played a role. Support for both cloud and on-premises environments enabled alignment with HIPAA and internal data residency requirements without architectural compromise.

Finally, real-time execution on operational data ensured decisions reflected current claim information without introducing synchronization or duplication risks.

Together, these factors made Nected a strategic decision layer—enabling higher throughput, lower cost per claim, and scalable operations without sacrificing trust or compliance.

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