Overview
A leading US healthcare insurance provider serving over 45 million members across commercial, Medicare, and Medicaid programs partnered with Sirma to drive digital transformation in risk and quality management. With a workforce of approximately 104,000 employees and an annual revenue nearing $190 billion, this insurer collaborates closely with major healthcare systems to enhance care coordination, compliance, and operational excellence. Sirma delivered an advanced AI-powered platform that streamlines complex healthcare workflows, enabling real-time risk analysis, quality management, and regulatory compliance across fragmented and multi-stakeholder care networks.
The Challenge
Healthcare organizations in the U.S. face significant pressure to comply with stringent federal regulations while maintaining consistent quality of care across vast networks. Many existing legacy systems are often siloed, inflexible, and lack transparency, particularly in workflows that involve multiple parties, such as providers, payers, and regulatory bodies. These limitations lead to delays in audits, increase the need for manual interventions, and reduce the ability to proactively manage insurance risks. The challenge is to redesign these processes using a unified solution that can adapt to evolving regulations, integrate various stakeholders, and provide clear insights in real-time.
The Project Scope
The project involved:
- Designing and developing 1health, an AI-powered platform enabling healthcare professionals to define, model, and execute complex multi-party workflows using plain language and smart modeling tools;
- Automating critical functions such as data validation, regulatory compliance checks, quality metric scoring, and audit reporting within a single consolidated environment;
- Ensuring that the platform supports scalability, security, and compliance with health data protection laws including HIPAA;
- Integrating with existing enterprise systems and data sources to synchronize workflows across the insurer and hospital networks;
- Supporting diverse user roles and facilitating collaboration between providers, payers, auditors, and regulators;
- Enabling rapid adoption enterprise-wide and continuous adaptability for new healthcare requirements.
The Solution
Sirma partnered with healthcare leaders to design and implement 1health, an AI-powered platform for defining and executing healthcare processes using plain language and smart modeling. The platform features natural language processing, allowing domain experts to build and adjust workflows without specialized programming knowledge. Embedded AI algorithms perform continuous data validation and compliance monitoring while dynamically scoring quality metrics and generating detailed audit trails and reports on demand. The unified platform enhances transparency across diverse parties, driving proactive risk management and quality improvement in real time. Its cloud-native architecture ensures high availability, security, and compliance in strict regulatory environments.
Results
- Rapid enterprise-wide adoption by a Fortune 50 insurer and a major US hospital system, collectively serving over 45 million insured members;
- Streamlined regulatory and care quality workflows significantly reducing audit times and manual work effort;
- Enhanced visibility and transparency fostering improved collaboration among providers, payers, and regulators;
- Increased agility in response to changing healthcare regulations and quality standards;
- Delivery of significant operational efficiencies and cost savings through AI-driven automation and risk mitigation.
We’ve used many platforms, but none allowed us to translate real-world healthcare processes into live digital workflows like this. With 1health, we’re not only compliant, we’re agile, efficient, and always audit-ready.
Technologies
- AI-powered workflow automation with natural language processing enabling no-code process modeling;
- Machine learning models for real-time data validation, compliance verification, and quality scoring;
- Cloud-native architecture supporting scalable, secure enterprise deployment;
- Integration APIs connecting with healthcare provider systems, payer platforms, and regulatory databases;
- Advanced analytics and reporting tools providing actionable insights and audit readiness;
- Robust data governance and security frameworks ensuring HIPAA and regulatory compliance.
Sirma’s Relationship with Client
Sirma engaged in a trusted partnership with the healthcare insurer and hospital system, emphasizing collaborative design, agile implementation, and continuous optimization of the 1health platform. Through close cooperation with clinical, compliance, and IT stakeholders, Sirma tailored AI workflows to address specific regulatory and operational challenges. Ongoing support and enhancements ensure the platform evolves with the healthcare landscape, reinforcing client leadership in quality-driven, compliant care delivery
