The claims conundrum payers can’t ignore

Claims processing is the engine that keeps a health plan running—but for many payers, it’s running on fumes. Legacy systems, fragmented workflows, and the sheer volume of claims contribute to backlogs, provider friction, and rising costs. In an environment where every claim is a moment of truth for member and provider trust, the pressure to evolve is real.

Enter: agentic automation—a new wave of intelligent, self-directed automation that doesn’t just follow rules, but actively makes decisions, adapts to complexity, and transforms how payers handle claims from end to end.

Why are payments so painful?

In a perfect world, the payments process would be streamlined, efficient, and error-free. But unfortunately, in the real world, it's highly complex, variable, and error-prone. Where are the pain points?

First, there’s the nature of the decisions themselves. Many require analyzing a significant amount of data—some of it unstructured or semi-structured—gathered from many different sources. These decisions aren't always straightforward and rule based; they require judgment, experience, and context to get right.

Second, most payments providers also must contend with legacy systems and siloed data that reduce flexibility, slow processes, and hamper informed decision making.

Third, ever-increasing volume and complexity of claims—coupled with ongoing shortages of skilled claims processing labor—creates stubborn backlogs and bottlenecks that lead to more complexity and employee burnout.

All this leads to ongoing operational challenges, including:

• Delays due to manual validation, outdated rules engines, and siloed data

• High error rates and rework from legacy tech and human intervention

• Provider dissatisfaction due to late payments and lack of transparency

• High operational costs and workforce burnout

• Inability to scale with new lines of business or value-based care models

• Manual interventions for validation and exception handling

• Difficulty in getting data to make informed, real-time decisions

• High costs due to rework, audits, and slow resolutions

In a nutshell, today’s payment claims systems weren’t built for tomorrow’s healthcare ecosystem. How can they escape from this conundrum? Agentic automation provides the pathway.

How agentic automation helps address the claims conundrum

Agentic automation has the potential to transform claims systems by allowing a great deal more of the process to be automated. To understand why and how, let's dive a little more deeply into the subject.

Agentic automation represents a new generation of AI-powered systems—goal-driven AI agents—that can go far beyond simple task execution. Unlike traditional RPA robots that require step-by-step instructions, these AI agents operate with autonomy. They don’t just follow workflows—they optimize them, with advanced capabilities to:

• Understand and set goals based on natural language prompts

• Perceive context

• Make decisions

• Adapt to dynamic environments

• Learn from outcomes

• Work effectively with tools and models, as well as people and robots, to execute work

In the claims world, that means AI agents can understand nuances in clinical documentation, apply policy rules in real time, coordinate across departments, audit intelligently, and resolve exceptions with minimal human intervention. Couple these capabilities with an automation platform that provides end-to-end orchestration, full governance and trust, rapid access to superior tools and resilient robots—and you have a pathway to transform the payment process, end to end.

This is not just theory. It’s already happening.

Putting agentic automation to work: three use cases to consider first

Some of our customers have already put agentic automation to work, with impressive results. Here are three examples of use cases that have generated rapid and significant improvements.

1. Pended claims automation

Pended claims—that is, claims requiring additional information before they can be processed—are a significant cause of delays and payment disruptions. By automating this process, one of our customers, Expion Health, has achieved a 600% improvement in throughput and a 99% success rate in claims resolution.

Key benefits:

• Faster claims processing

• Reduced delays and bottlenecks

• Improved payment accuracy

• Reduced cost per claims

2. Claims audit automation

Manual audits are time-consuming and prone to errors. Automation captures claims, extracts data, and identifies discrepancies, allowing for faster, more accurate and robust audits. For example, a Regional Blue Plan reduced audit times from 3.5 hours to minutes, dramatically increasing audit capacity and ensuring accurate claims.

Key benefits:

• Faster, more accurate audits

• Significant time savings

• Reduced overpayments

3. Appeals and grievances automation

As the healthcare ecosystem becomes more complex, appeals volume has been increasing—putting even more pressure on manual approaches and increasing customer-dissatisfying delays and backlogs. One of our customers is applying automation to streamline the process from intake to rendering a decision and notifying the provider/member. The result: a 75% reduction in turnaround times.

Key benefits:

• Faster turnaround times and decisions

• Reduced administrative burden; research, follow up, and processing time

• Compliance and SLA adherence

These are three use cases that have delivered proven, accelerated results for UiPath customers—and therefore are ones that you might wish to prioritize in your own efforts. But they are certainly not the only applications for agentic automation in payments. Others places you might consider leveraging AI agents include:

• Claims load and cleanup

• Pended claims review and resolution

• Prepayment pricing validation

• Correspondence generation

• Overpayment recoveries

• Coordination of benefits (COB) research and determination

• Claims testing

• Claims audit

• Configuration monitoring

One thing is clear: as claims volumes and complexity grow, agentic automation will play an even more vital role in streamlining operations. It will enhance decision making with automation tools and further improve efficiency across the entire claims lifecycle, from intake to adjudication.

Conclusion: The path to efficient claims management

Traditional claims management methods are no longer sustainable. With growing claims volumes and increasing complexity, payers need a more efficient way forward. Agentic automation provides the tools to transform the claims process—reducing costs, enhancing accuracy, and speeding up processing.