USA46: Why a Health Insurer Mistook Claims Automation for Enterprise Architecture Transformation
- Sunil Dutt Jha
- Jul 29
- 1 min read
Updated: Oct 29
Overview:
This case is part of a 100-diagnostic series exposing how US insurers have mislabeled operational automation as “Enterprise Architecture reform.”
A recurring pattern is equating claims processing speed with architectural maturity.
Claims were auto-adjudicated faster, portals displayed status instantly — yet the enterprise anatomy linking eligibility, provider data, benefits rules, and appeals workflows was never modeled.
P1–P6 Insight Preview:
Automation improved claims processes (P2) and component performance (P4–P5), but lacked strategy alignment to care delivery (P1) and integrated system behavior (P3).
Business ops (P6) still resolved exceptions manually; tech ops (P6) maintained duplicated rule sets.
Role Disconnects:
CEO: “We’re processing claims in record time” — but exceptions still choke the pipeline.
CIO: “We’ve digitized the claims journey” — yet rules logic is duplicated in multiple places.
Sales Head: “Faster claims mean happier members” — but disputes still escalate slowly.
Chief EA: “We have workflows, not an enterprise model”
Head of Claims: “The system moves cases faster, but exceptions still hit my desk daily”
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