From Claim Submission to Settlement: Where Claims Automation Actually Delivers ROI
very insurer knows claims automation promises faster processing and lower costs. But when it's time to build the business case, the conversation stalls. "Faster" how much? "Cheaper" where exactly?
The truth is, ROI doesn't come from automating everything. It comes from automating the right decision points—the repeatable, high-volume steps where manual effort creates bottlenecks and errors compound. The hidden costs of manual claims vetting often hide across speed, cost, leakage, experience, and compliance.
This guide maps where automation delivers measurable value—and what metrics prove it.
The Claims Journey: Where Automation Fits
A typical claim moves through six stages: submission, intake and validation, triage, vetting and adjudication, settlement, and post-pay review. At scale, "the queue" becomes the work. Every manual touchpoint adds latency, error risk, and cost.
The goal isn't eliminating humans—it's focusing human expertise on decisions that actually need judgment.
ROI Zone #1: Intake & Validation
This is where automation pays back quickest. Claims stall at intake because of missing documents, incorrect formats, or duplicates.
What to automate: Completeness checks, document capture and data extraction—automate intake and document extraction to eliminate manual entry—format normalisation, duplicate detection, and basic fraud flags.
Metrics: First-pass acceptance rate, rework rate, time-to-triage.
A 20% improvement in first-pass acceptance can cut intake cycle time in half.
ROI Zone #2: Eligibility, Benefits & Preauth Matching
This is the control gate before payout. Every claim that shouldn't be paid but slips through becomes leakage.
What to automate: Member eligibility verification, preauth matching (codes, providers, dates, policy terms), benefit application, and pre-authorization controls that catch mismatches before adjudication.
Metrics: Prevented invalid payouts, pended claim rate, escalation volume.
McKinsey's research confirms eligibility automation is one of the highest-impact interventions for reducing processing time and errors.
ROI Zone #3: Straight-Through Processing
This is the biggest capacity unlock. Routine claims—standard procedures, clean documentation, known providers—shouldn't require human review.
What to automate: Rules-based adjudication for standard benefits, auto-approval when signals are clean, exception routing only for cases needing judgment.
Metrics: STP rate, claims per reviewer, TAT distribution (median and P90).
Deloitte's claims research identifies AI-driven STP as a defining capability. The target? 60–80% of routine claims without manual intervention—meaning your team handles 3x the volume without burning out.
ROI Zone #4: Exception Handling with Context
Exceptions are inevitable. The question is whether your team handles them efficiently.
What to automate: Enrichment (claim history, similar decisions, provider patterns), risk scoring and prioritisation, routing to the right specialist with full context attached.
Metrics: Exception cycle time, appeal rate, decision consistency, audit outcomes.
When reviewers see claims with context already assembled, they decide faster and more consistently.
ROI Zone #5: Settlement & Post-Pay Controls
Leakage compounds after payment—duplicates that slip through, billing patterns that drift, overpayments undetected until audit.
What to automate: Decision logging, provider pattern detection, anomaly detection in claims, overpayment flagging, and recovery workflow triggers.
Metrics: Leakage rate, recovery rate, audit findings, denial accuracy.
A 1% leakage reduction on high-volume portfolios can translate to millions in annual savings.
What an ROI Model Looks Like
Baseline: Annual claim volume, cost per claim, average TAT, leakage rate, appeals rate, staffing cost.
Improvements: STP rate increase (e.g., 30% to 65%), TAT reduction (days to hours for clean claims), leakage reduction (15–25%), capacity gain without proportional headcount.
Output: Annual savings, payback period, capacity value.
To see Curacel's outcomes across real deployments, or see a claims automation case study, the numbers speak for themselves.
Enterprise Buyer Checklist
What to look for in a platform: configurable rules engine, exception routing with explainability, audit logs and decision trails, integrations with core admin and provider systems (ACORD standards support is a plus), enterprise security, and reporting tied to real KPIs—not vanity metrics.
For motor-specific considerations, see what to automate first in motor claims.
Implementation Sequence
Don't automate everything at once. The highest-ROI sequence: intake and validation (quick wins), eligibility and preauth controls (prevent leakage), straight-through processing (unlock scale), exception handling (improve quality), then post-pay controls (catch and recover leakage).
Start where your pain is sharpest, prove value, then expand.
Ready to Map Your ROI?
Claims automation isn't about technology for its own sake. It's about capacity, control, and confidence.
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