CASE STUDY
Thousands of Backlogged Claims Cleared in 60 Days — No New Headcount: Automated Case Intake for a Healthcare Reimbursement Law Firm
Key Results
| Backlog Reduction | Thousands of previously unreviewed claims processed and triaged in the first 60 days |
| Statute of Limitations | Identified qualified cases before expiration that would have been missed under manual review |
| Accuracy | Automated case analysis applied consistent eligibility criteria across all records, reducing human variability |
| Compliance | Full audit trail built into every case record, supporting litigation defensibility requirements |
SERVICE AREA
INDUSTRY
CHALLENGE
Thousands of backlogged medical claims expiring before attorneys could review them
This large U.S. based law firm specializes in medical claim denial appeals and is experiencing an issue that is creating a risk of loss of both revenues and clients. The issue is that there are thousands of cases (potential new clients) sitting in a backlog as statutes of limitation are silently running out. The only way to get a case reviewed by attorneys or paralegal staff is by reviewing hundreds to thousands of pages of medical records prior to determining if there are enough merits in order to proceed with filing a lawsuit. Due to the sheer volume of cases coming into the firm, it became apparent that the manual review process would never be able to keep up. In addition to losing qualified work because of the lack of resources, the firm is also experiencing a loss of income and lost opportunity costs as unqualified work continues to consume billable hours and potential revenue-generating opportunities continue to age out while awaiting review. The leadership team was looking for a solution that would allow the firm to increase its case intake capabilities while simultaneously decreasing the need for additional staffing to accomplish this objective. Leadership wanted a solution that could provide a consistent and defensible evaluation of all cases in the firm’s pipeline.
SOLUTION
Custom case intake platform with automated record analysis, compliance audit trail, and EHR integration
SCIGON developed and delivered a custom case intake system that provided automation for requesting and retrieving patient information contained within medical records. Once received, those same records were processed through an analytical layer (which supported processing of structured data types as well as unstructured clinical notes) that extracted relevant content from various forms of documentation. Following analysis, the software compared the contents of each case against the firm’s existing litigation eligibility criteria and legal precedent library. Any cases that met or exceeded litigation eligibility criteria were assigned to the most applicable attorney queue along with a summary document and evidence index. Those cases that failed to meet litigation eligibility criteria were documented, closed, and allowed attorney time for working on matters that actually impacted their area of expertise. Throughout the development phase, SCIGON employed quality engineering methodologies to ensure that all analysis rules were tested and proven against past outcomes. All integration points with EHRs were load tested using realistic volume scenarios. The audit trail architecture was created to satisfy litigation defensibility requirements. As such, the resulting platform enabled the firm to increase its case intake capacity scalably, maintain a compliance documentation trail, and recover qualified cases previously hidden by its case backlog.
