Health plan automation cuts administrative costs when it removes manual handling, prevents avoidable rework, and completes routine transactions correctly the first time. The strongest business cases combine reliable provider and member data with a specific workflow change, then measure cost per completed transaction and the work still requiring human review.
The 2025 Index Report identifies a $21 billion industry savings opportunity from transitioning to fully electronic transactions. That is an industry benchmark, not a forecast for an individual health plan. To identify a realistic opportunity in 2026, start with your own transaction volumes, handling costs, and exception rates. You can estimate these values yourself, or use the ROI calculator that is included as a part of the 2025 Index.
A process is a promising candidate to reduce administrative costs when it runs frequently, follows clear rules and receives sufficiently reliable inputs. Eligibility inquiries, claim status requests, payment reconciliation, and routine coverage investigations are useful places to examine.
Provider data maintenance also deserves attention. Repeatedly collecting an office address, resolving conflicting rosters, or rekeying the same profile can consume staff time before a claim or credentialing decision even begins. Improving the shared record can reduce work across several processes.
|
Workflow |
Work automation can reduce |
Measure the result |
|
Eligibility and benefits |
Repeated lookups and manual entry |
Cost per completed inquiry |
|
Claim status |
Avoidable calls and repeated portal checks |
Inquiries resolved without staff intervention |
|
COB investigations |
Outreach and manual coverage research |
Handling time, verified resolution rate and claim delay |
|
Provider data maintenance |
Duplicate collection and repeated corrections |
Touches per change and recurrence of errors |
|
Claim payment reconciliation |
Manual matching and follow-up |
Cost per reconciled payment and unresolved balance age |
These represent workflow opportunities to evaluate, not a claim that any single product can automate every function. The appropriate technology and responsible team will vary by use case.Use better data to prevent work from entering the queue
Automating a process built on outdated coverage or conflicting provider records can accelerate mistakes. Before expanding automation, identify the input failures that create the most exceptions. Common examples include missing termination dates, inconsistent identifiers, and ambiguous practice locations.
Define which cases can proceed automatically and which need review. A complete, validated coverage record may support a routine workflow. Conflicting effective dates should reach a designated owner. Preserve the reason for each exception so recurring issues can be fixed at their source.
DataSpring’s member data solutions support payment accuracy, while provider data management supports provider information used across operational workflows. Reliable inputs help organizations get more value from the systems they already operate.
Use a consistent unit of work. For example, measure the cost to resolve a COB investigation rather than the cost to send an automated request. A request that creates three follow-up tasks has not delivered the same result as a resolved investigation.
A practical annual model is eligible volume multiplied by the proportion actually automated, multiplied by net handling cost avoided per completed transaction, less incremental technology, implementation and oversight costs.
Example: an organization processes 100,000 eligible transactions a year. If 60% shift to a workflow that avoids $4 of handling cost per completed transaction, the gross annual capacity value is $240,000. If first-year implementation, technology and oversight costs total $150,000, the modeled first-year net benefit is $90,000, or 60% ROI on those costs.
This is not a DataSpring result or pricing estimate. The $4 assumption must include any remaining manual review and rework. Released staff capacity becomes a budget saving only if the organization can reduce spend or avoid additional hiring; otherwise, report the time as capacity available for other work.
Keep claims payment improvements separate from administrative savings. Avoided overpayments are a different benefit from reduced processing labor, and the same dollar should not appear in both categories.
In a DataSpring case study of a regional health plan, the organization reduced outbound coverage-verification calls by 65% in its first six months using the COB solution and Member Data Portal. The case study also reports an average COB resolution time of 1.5 business days for work that previously took weeks.
Those results illustrate how access to coverage information can change the work itself. They do not establish that every organization will achieve the same reduction, and fewer calls should not be presented as an equivalent percentage reduction in total administrative spending.
CMS-0057-F introduced prior authorization process requirements beginning primarily in 2026, while its API requirements generally begin in 2027. For affected payers, this makes 2026 a useful time to review intake, denial-reason capture, reporting, and integration readiness. Scope and applicability differ by requirement; consult the CMS final rule fact sheet.
Automation can organize and route information, check completeness, and reduce repeated entry, while clinical decisions still require the appropriate clinical governance. Evaluate AI features against a defined task and observed error rate, rather than treating the presence of AI as evidence of savings.
Choose a high-volume process with measurable handling costs, stable rules, and usable data. A narrower workflow with a clear owner is often easier to evaluate than a broad transformation with unclear attribution.
No. A portal may replace a phone call while still requiring someone to log in, search, copy, and reconcile information. Measure remaining human steps across the whole transaction.
Compare a baseline with pilot results using equivalent case types and volumes. Include exceptions, rework, quality checks, and ongoing costs, then have finance validate the method.
Use the Index Report to identify cost and time savings opportunities, then test a workflow with your own data. To discuss how to enhance your business for greater ROI, book a consultation.