Strategy and Solutions
The client was a mid-sized health insurance plan processing over 4.1 million medical claims annually across commercial and government programs. Despite steady membership growth, the plan faced mounting revenue leakage due to claim denials, slow appeals, and manual revenue cycle workflows. Denial management relied heavily on post-facto reviews, spreadsheets, and staff experience, resulting in missed recovery opportunities.
To improve financial performance and reduce administrative burden, the health plan partnered with Zymr to apply AI-driven intelligence across denial prediction and appeals automation.
Claim denials were increasing in volume and complexity, driven by evolving payer rules and coding requirements. Existing workflows identified denials only after adjudication, making recovery reactive and inconsistent. Appeals were manually prepared, time-consuming, and often submitted too late or without sufficient supporting evidence. The plan needed a proactive approach that could predict denials earlier, prioritize high-value claims, and automate appeals while maintaining accuracy and compliance.
Zymr helped the health plan shift from reactive denial management to proactive, AI-driven revenue protection. By predicting denials early and automating appeals intelligently, the plan recovered significant revenue, reduced administrative workload, and improved overall revenue cycle efficiency.
Zymr implemented an AI-powered revenue cycle intelligence platform focused on denial prevention and automated recovery.
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