Applying automation to healthcare and medical claims management solutions can go a long way in reducing overall costs and increasing efficiency across the board. Ranging from hospitals to independent clinics, all healthcare service agencies state cost efficiency and service excellence among their priorities. Automation of billing and medical claims management can be critical to achieving these priorities. The crux of automation can be defined as the deployment of IT systems that control functionalities and reduce human involvement in the organization of data and monitoring of services. The use of automated IT systems has been maximized in other industries for many years now. However, the healthcare industry is now turning to these solutions for increased efficiency. Within the industry, the medical claims department stands to greatly benefit from medical claims processing solutions.

Automation has always carried with it a negative and false notion of being directly responsible for the reduction in jobs. For example, when automation was introduced into the automobile industry, people assumed it would reduce the workforce of automobile workers. However, what actually occurred was the reduction of redundant jobs by the automobile industry workers and increased focus on intelligent and satisfying arenas of work. The same holds true for the healthcare industry. Manual data entries are handled by automated processes, enabling the medical staff to focus on intelligent analytics and supervisory processes.

Common Challenges in Manual Claims Processing

Common Challenges in Manual Claims Processing

The medical billing and coding industry and the reimbursement process is constantly evolving in healthcare. With a focus on patient convenience, the current reimbursement models take on more of the risk. This takes the pressure away from the patients and places it on the reimbursement agencies that need to adhere to stricter timelines and protocols. There are three distinct avenues within the claims management process – financial, technical, and operational. The financial department deals with accounts receivable, collection rates and denials. The technical side deals with systems, processes and interactions. Finally, the operational side looks into staff matters, communication with vendors and the overall workflow. Therefore, insurance claims management comes with its own set of pain points. They are as follows: Manual claims processing presents various challenges that can impede efficiency and accuracy within insurance operations. From human errors to time-consuming tasks, the reliance on manual procedures can lead to delays in claim adjudication and reimbursement.

Therefore, manual insurance claims management comes with its own set of pain points. They are as follows:

Delays in Claims Submission: Processing each claim involves accumulating a huge amount of data from health records, diagnoses from doctors, test results, payment details, and more. This data is crucial for reviewing and finalizing the claim. However, collecting and processing this data manually takes a lot of time and effort, and causes delays to the submission process.

Slow Claim Resolving Time  – The claims have to be resolved within the mentioned time which is different from state to state. However, in practice, delays in claims resolution are among the most common problems of claim processing, and this occurs due to wrong coding and miscommunication between the provider, carrier, and patient.

Regulatory Incompliance and Fraud: Insurance companies have to carefully follow the rules and regulations by implementing measures to detect and prevent fraud. This makes managing claims even more complex as they must navigate regulatory compliance with fraud prevention efforts.

Mismanagement of Data Security and Integration –  Insurance companies face challenges in handling large volumes of data flow from various sources. They often grapple with integrating this information efficiently which causes delays in processing claims.

Some other challenges that are faced during insurance claims management are:

  • Limited resources dedicated to the revenue cycle
  • Lack of expertise in the claims adjudication process
  • Strict timeline demands
  • Evolution and changes in reimbursement strategies
  • Rise in billing costs
  • Organizational incompetence
  • Lag in responses
  • Disparate standards and inefficiencies

In the current reimbursement system, either a single analyst or a group of analysts have to consolidate through a heap of lists and reports and make meaningful connections for filing. The lengthy processes cause crucial information to be lost, wastes employee time that can be put to better use, delays patient care, causes extreme confusion on the right protocols and prevents consumer satisfaction. Incorrect information puts a further burden on medical claims clearing house. To be able to streamline the medical claims process, many factors need to be considered.

The large amount of paperwork that comes in bits and pieces, which is required to be consolidated and tediously filed. There is a high chance of human error, which results in further delays and claims rejections.

Furthermore, gaining access to complete patient data is a hurdle faced by most healthcare providers. The outsourcing culture causes further complications. Additionally, the quality of data available is not error-free, and neither is it efficiently accumulated.

The Need of the Hour – Automated Healthcare Medical Claims Management

If the current inefficiencies in the medical claim management system had to be attributed to one over-arching reason, it would be the manual nature of the system. Automation offers significant advantages in streamlining and optimizing the claims processing workflow. By leveraging automation technologies, organizations can minimize errors in manual processing to ensure data accuracy. With built-in validation checks and audit trails, automation ensures compliance with healthcare regulations such as HIPAA, CMS guidelines, and other industry standards, minimizing the risk of penalties and legal issues, reducing costs, and enhancing the quality of claims processing operations.

There are several healthcare medical claims management software options available that standardize workflows and provide access to analytics for performance improvement. The new model of reimbursement, one which looks at the patient as a priority can be efficiently executed through the right kind of technology. When choosing an automated medical claims management solution, be sure to look for these key pointers:

Top Reasons to Deploy Automated Medical Claims Management Solutions:

Below are the top reasons to deploy automated medical claims processing solutions:

Top Reasons to Deploy Automated Medical Claims Management Solutions

Reduced Labor: Automated healthcare claims management helps in the reduction of manual tasks that are executed faster and more efficiently by technology solutions. This means that the employees in the organization can focus on tasks that are higher functioning roles and the ones that require more clinical experience.

Higher Quality: Electronic claims processing uses automated systems that are free of errors, commonly made by human entries. This is because the technology usage is consistent in its data entry features and its analysis of the very same data.

Lower Supply Cost: Claims processing in healthcare, when manually undertaken, involves a large amount of paperwork. When the medical claims process is automated, through claims processing software, there is a direct reduction in paper and other materials.

Higher Predictability: Through claims management solutions, there is an accurate prediction of claims that are likely to be rejected or returned for more information. This avoids unnecessary back and forth and works towards cost and time efficiency. With predictable outcomes comes early intervention for seamless processing.

Data-based Analysis: The claims adjudication process, when automated, uses the data to churn out meaningful analyses that can be used to increase performance and optimize processes. These programs provide information on means through which functionality can be improved.

Faster Claims Processing: Automating healthcare medical claims management software can lead to faster claims processing as compared to manual processing. It is a smart move to automate claims processing as it reduces process handling time by 70%.

Substantial ROI: As high claims volumes are processed faster, payments are received more quickly and consistently. This saves time as there is no need to go back and fix errors or deal with a backlog. Employees do more in less time, and increased human productivity yields higher returns and retention.


Key Features of Custom Medical Claims Management Software

Key Features of Custom Medical Claims Management Software

Gone are the days when medical claims analysts needed to perform tedious and mundane tasks while being buried in a pool of paperwork. Additionally, the endless phone calls and emails and complicated back-and-forth processes are replaced with real-time checks of claim status and instant responses to queries.

Below is a summarized checklist of features that are essential to healthcare claims software development:

Claims Tracking: Automated claims management software allows for seamless tracking of claims, from submission to resolution, enabling transparency throughout the process.

Real-time Eligibility Verification: This feature enables instant verification of patient eligibility for insurance coverage, ensuring accuracy, and reduction in claim denials.

Automated Adjudication: By automating the adjudication process, the software efficiently evaluates claims based on a predefined set of rules, reducing the need for manual intervention and processing time.

Denial Management: Automated claims management software helps identify and address claim denials by analyzing the reasons for claim denials, and implementing corrective measures to eliminate future denials.

Multi-device Claim Initiation: Users should be able to start the claims process from different devices like computers, smartphones, and tablets for easy accessibility and convenience.

Third-party Access Opportunities: Enabling external parties such as healthcare providers or insurers to access the system to ensure collaboration and enhance transparency throughout the claims process.

Comprehensive Support: Providing all-rounded assistance, including user-training troubleshooting, and customer service, to ensure smooth implementation and ongoing maintenance support.

Additional Features of Healthcare Medical Claims Management Software:

Additional Features of Healthcare Medical Claims Management Software

Health Plan Administration: We support health plans with state-of-the-art technology, process expertise, and a global workforce to ensure operational efficiency, overcome staffing limitations, and boost market expansion.

Claims and Administration Automation: We offer all-inclusive, end-to-end claims management solutions for the intake and data extraction of mission-critical communications. This reduces the cost of document processing and enhances data quality.

Payment Integrity: We combine multiple data sources and cutting-edge technologies with extensive industry expertise to help health plans recover more overpayments while minimizing provider and member abrasion.

Community Health: Conduent Healthy Communities Institute (HCI) helps organizations understand communities and populations. This makes it easier to invest in partnerships and initiatives that address social determinants of health and improve the patient care services available.

Cost for Automation in Claims Management Software

Cost plays an integral role in determining the benefits of automation in claims management software. One must consider how much it will cost to set everything up at the beginning like getting the software and licenses. There are also ongoing costs like maintaining the software and keeping it up-to-date. The initial setup can range from tens of thousands to hundreds of thousands of dollars, depending entirely on how complex the solution is. Moreover, any add-ons also need to be considered in the budget. Although setting up can be an expensive process, automation can result in substantial savings over time. It can result in cost savings of 15-20% of the initial setup owing to the lower operational costs and faster claims processing.

7-Step Approach to Automating Healthcare Claims Management Software:

When opting for automation through healthcare claims management software, the key is to deploy a solution that not only increases the efficiency of claims processing but also one that offers interoperability and extensive capabilities that can adapt to evolving market requirements. The overall benefit will be noticed by policyholders, insurance companies, and healthcare providers. This is how an end-to-end solution will tackle claims processing through the entire lifecycle – from claim creation to claim adjudication tracking and finally to reimbursement. Below is our 7-step approach to successful automation of claims management:

1. Automated Population of Claims Data:

This feature is a must-have and eliminates the requirement for manual intervention of data reentries. The system is geared to automatically generate the data based on initial entries. Thus, the data is organically created, generated, and programmed efficiently.

2. Patient Coverage Verification:

This is an excellent way to cut down on delays wherein the eligibility of the patient’s coverage can be confirmed electronically and payment recovery processes can be immediately started. This eliminates the frustrating time lag owed to inactive coverage causing denials.

3. Error Identification and Rectification:

The automated software should be able to identify errors during claim submission and offer suggestions for rectifications. These errors can then be eliminated before submission with automated suggestions.

4. Highlighting discrepancies:

Opt for a solution that is capable of highlighting claims that are likely to be rejected or refused. This will enable faster problem-solving and efficiency. Based on past inputs, the software can predict claims that are potentially those which could be denied. Prioritization becomes much easier through this feature, with attention demanded towards areas of immediate attention, such as pending matters.

5. Electronic Submission of Claims:

Some automation solutions come with the capability to create, verify, and submit claims electronically. This erases the need for manual paperwork. Accessibility is increased through electronic documentation and records.

6. Real-Time Updates and Checks:

High-performance automation claims management software provides the capability of real-time access to current and past claims, along with areas that need to be checked. It also reduces the need for manual processing. Finally, professional claims can be adjudicated in real time through interactive transactional experiences.

7. Monitoring of Accounts Receivables (A/R):

Quality execution allows the software to provide access to accounts and pending matters, thereby reducing costs related to policy and medical claims. Additional features include tracking of recoverables and fraud detection.

Optical Character Recognition – A Key Requirement:

Even though automated claims management solutions have been prevalent for a number of years now, they have constantly evolved to provide higher satisfaction to all the entities involved in the healthcare industry. One such feature is the Optical Character Recognition (OCR), which has high potential in diminishing the possibility of serious errors in coding and claims filing. This is done through efficient scanning of documents and electronic programming and isolation.

Selecting the Right Automated Claims Management Software

Selecting the Right Automated Claims Management Software

Selecting the right automated claims management software is necessary for the smooth functioning of operations within a healthcare organization. To make an informed decision, consider these factors:

Scalability: The software should have the capacity to handle increasing claim volumes and adapt to the growing needs of the organization without compromising on the quality of the work and performance.

Integration with Existing Systems: The software must seamlessly integrate with other systems to facilitate smooth data exchange, streamline workflows, and maximize efficiency.

Regulatory Compliance: Software should comply with industry regulations and standards to ensure data security, confidentiality, and legal adherence.

Vendor-Support: Reliable vendor support is essential for timely assistance, updates, and maintenance to address any issues or obstacles during implementation and operation.

Cost-effectiveness: Evaluating the cost of ownership and ROI is important to determine whether the benefits of the software will justify its upfront and ongoing cost, ensuring optical budget allocation.

By understanding these factors, healthcare organizations can select the automated claims management software that aligns with their specific needs and requirements.


Whether it is a general fatigue of the manual processes involved in medical claims processing, the higher costs associated with it, or the inefficiencies and delays that are being experienced, the solution is close at hand.

Automating healthcare medical claims management solutions can streamline the process through the entire lifecycle of claims submission. Whether it is the convenience of electronic data entry, or validation through the use of technology, or even the flexibility of errors being flagged prior to submission – the benefits are endless.

These automated solutions are poised to create satisfaction among all entities in the healthcare industry, through a diminished financial burden. Make a careful choice from the many options that are available since there could be some that offer limited features for the same price points as those that come with the entire spectrum of beneficial features.

Finally, ensure that your software selection is one that is easy to use, rich in features, and user friendly in its approach and has cross device functionality. The software should be well integrated into the EHR system of the healthcare agency or practice. There are also several software options, available in the market, which can be customized to particular requirements.

OSP is a trusted healthcare software development company that delivers bespoke solutions as per your business needs. Connect with us to hire the best talents in the industry to build enterprise-grade software.


How can we help?

Fill out the short form below or call us at (888) 846-5382


Discuss Your Project Handover with a team of expert Book a free consultation arrow_forward