ADRES, a key entity in Colombia’s healthcare system, manages public resources to ensure medical care access for millions of citizens. Facing a growing volume and complexity of medical claims—particularly those related to traffic accidents without SOAT insurance—the organization needed to transform its audit processes. The goal was to improve efficiency, accuracy, and decision-making while ensuring strict regulatory compliance and safeguarding public resources.

The audit process required reviewing thousands of monthly claims composed of unstructured documents, demanding high levels of precision and regulatory adherence. Previously, audits were conducted manually by third parties, leading to long processing times, increased risk of errors, limited data quality, and delays in decision-making. This constrained ADRES’ ability to respond efficiently and scale operations.

The transformation significantly improved ADRES’ operational efficiency, control, and responsiveness. Audit processing time was reduced by approximately 96%, from five hours per case to just 5–10 minutes. The cost per audit decreased by nearly 75%, from COP 48,000 to around COP 12,000.

Response times improved by up to 40x, enabling faster decision-making and higher processing capacity. Data quality improvements allowed for more accurate, data-driven decisions, while enhanced traceability strengthened transparency and control over public resource management.

The model achieved accuracy levels of 87% in medical components and 92% in medication audits, reinforcing reliability and consistency in the audit process.

As ADRES Director Félix León Martínez stated: “This system revolutionizes the claims process, providing the organization with greater capacity, quality, and efficiency in auditing.” He added that it also benefits healthcare providers by reducing administrative discrepancies, improving data validation, and optimizing payment cycle times.

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