Healthcare Claims Management Software

When a growing radiology practice in the Pacific Northwest couldn’t keep up with benefits verification, they had to rely directly on patient interpretations of their healthcare plans. 

Given the complexity of insurance plans today, that was a mess.

Prior authorizations and patient estimate errors became rampant, as did denials and delayed reimbursements. These shortcomings led to a complicated, lengthy back-end revenue cycle. As the business office director explained, 

“High deductible plans and complex payer-network-shave put an increased strain on clinical operations, revenue cycle workflows, and the patient experience."

The group sought AI-driven, automated healthcare claims management software that would extract key benefits information from plans before service and then provide price transparency to patients. They hoped both would improve their collections and prevent a hefty portion of denials.  

Today, with healthcare claims management software in place, their

• denials have dropped by 50%
• bad debt has dropped by 45%
• benefit verification is now 85% automated

When you automate eligibility checks and use software to actively manage denials, staff work gets streamlined, claims accuracy improves, and admin costs diminish — all while you ensure you bill the correct payer, alert staff to prior-authorization needs, and avoid denials. 

If healthcare claims management software is in your organization’s future, review this post to understand the benefits it brings. For every software option you review, you want to know what automation and workflow optimization features are available. You probably also need to know whether your options have real-time visibility and comprehensive reporting. In the hacker age, reassuring the C-suite that security measures are in place to protect sensitive patient and financial data goes a long way, too. 

Here, you’ll find these answers and more as you consider healthcare claims management software. 

What is healthcare claims management software? 

Claims management software is a digital platform designed to streamline and automate the entire lifecycle of insurance or healthcare claims, from initial submission through final settlement. By centralizing all claim-related data, documents, and workflows in one system, organizations can efficiently track, process, and resolve claims and denials while reducing manual effort and minimizing errors. 

By automating routine tasks and integrating with other core systems, the software helps reduce administrative burdens, accelerate payment cycles, and enhance the overall experience for both staff and patients. Ultimately, it empowers organizations to handle even complex claims efficiently, make smarter decisions with actionable insights, and maintain stronger relationships with payers and patients.

Healthcare claims management software is now widely adopted across the industry, with most healthcare organizations utilizing it as a core part of their revenue cycle operations. The Business Research Company projects the market size for healthcare claims management software to more than double by 2033, reflecting a strong and ongoing trend toward digital transformation and automation in claims processing.

Take a quick, self-guided tour through powerful claims and denial management software. 

Integrations

Healthcare claims management software typically integrates with your current IT platforms. Common integrations include:

• Electronic health record (EHR) systems: For accessing patient demographic, clinical, and encounter data necessary for claim creation.
• Practice management systems (PMS): Often, claims management functionalities are bundled within PMS or tightly integrated with them, covering scheduling, billing, and reporting.
• Revenue cycle management (RCM) software: Claims management is a core component of RCM, so integration is fundamental. Some claims management software is sold as part of a comprehensive RCM suite.
• Medical billing software: Claims management features can be standalone or integrated within medical billing systems.
• Clearinghouses: For electronic claim submission and status retrieval.
• Payer portals: For direct submission, status checks, and retrieving remittance advice.
• Patient accounting systems: To reconcile payments and manage patient financial responsibility.

Tasks carried out by healthcare claims management software

Even a brief review of these tasks imparts the amount of work that AI-driven, automated healthcare claims management software lifts from today’s short-staffed revenue cycle departments. Keeping all of these tasks on track often overwhelms RCM staff. The software steps in with: 

• Patient eligibility and benefits verification
• Claims preparation and creation
• Claim scrubbing and validation
• Electronic claim submission (EDI)
• Claims status tracking
• Document management
• Claims adjudication support
• Denial management and appeals
• Payment posting and reconciliation
• Reporting and analytics
• Integration with healthcare IT systems
• Compliance management and audit trails
• Risk assessment and fraud detection
• Billing and invoicing
• Customizable workflows and dashboards

Layer frequent payer policy and governmental regulation changes on top of these tasks, and it’s no wonder denial rates keep rising. 

As Jason Consodine writes in Medical Economics, 

 "Providers are seeing payer policy changes occurring more frequently. The inconsistency of these payer rules adds more layers of responsibility for the provider in the claims submission process and creates more room for error, further complicating the situation."

When automation takes away the busy work, employees get to work on more engaging, challenging work.   AKASA reports that claims automation saved Nebraska Methodist Health System 1,800+ hours per month of busy work, improving RCM staff job satisfaction. 

How does claims software enhance accuracy in claims processing?

Healthcare claims management software not only executes these tasks, it automates tasks, reducing the chances of human error. By automating data entry, validation, and error-checking tasks ripe for human mistakes, it doubles down on processing accuracy. 

Specifically, the software cross-references claim information — such as patient demographics, procedure codes, and insurance details — against internal databases and payer rules, immediately flagging anomalies or missing data before submission. 

AI-powered tools further improve accuracy by learning from historical claims, identifying patterns that lead to denials, and updating rules to catch emerging issues. This automation ensures consistent, standardized workflows, reduces transcription and coding errors, and improves “clean claim rate” or the percentage accepted on the first submission. The higher the clean claim rate, the fewer the denials, the less rework, and the faster reimbursements.

Finally, by integrating with EHRs and providing real-time eligibility checks, claims management software guarantees that every claim aligns with payer requirements and clinical documentation, ultimately optimizing both compliance and financial outcomes.

Types of healthcare claims management software

Healthcare claims management software comes in several types, each designed to address the unique needs of different healthcare organizations and workflows. The main types include:

• Standalone claims management systems: These platforms focus exclusively on automating and managing the claims process, from creation and submission to tracking, adjudication, and payment posting. They are often used by billing companies or larger healthcare organizations that require robust, dedicated claims capabilities.
  
• Integrated practice management or revenue cycle management (RCM) suites: Many claims management features are bundled within broader practice management or RCM software. These suites combine claims processing with scheduling, billing, patient records, and reporting, providing a unified solution for clinics, hospitals, and group practices.  
• EHR-integrated claims modules: Some electronic health record (EHR) systems include built-in claims management modules. This integration allows for seamless transfer of clinical and billing data, reducing manual entry and errors while supporting compliance and efficiency.
  
• Specialty-specific claims software: Certain solutions are tailored for specific medical specialties, such as mental health or dental practices. These systems address the unique coding, billing, and insurance requirements of particular fields.
  
• Risk and compliance-oriented systems: Larger healthcare organizations or those with complex risk profiles may use claims management software that emphasizes advanced analytics, automated workflows, fraud detection, and regulatory compliance.
  
• Clearinghouse-connected solutions: Some claims management software is tightly integrated with clearinghouses, enabling direct electronic submission, real-time eligibility checks, claim scrubbing, and remittance processing without the need for third-party intermediaries.
  

Each type may offer cloud-based, on-premises, or hybrid deployment options, and can include advanced features such as real-time status updates, customizable workflows, reporting, analytics, and AI-powered automation to further streamline the claims process and improve financial outcomes.

Healthcare claims management and denial management software: close cousins

Claims management and denial management software, while connected, are distinct components within healthcare revenue cycle management. Claims management software addresses the entire claim journey— from creation and submission to tracking and payment — and often includes basic denial avoidance features. 

Denial management software, however, zeroes in on preventing and resolving claim denials. Many vendors offer integrated solutions that merge these functionalities due to their synergy in the revenue cycle. Notably, vendors prioritizing revenue recovery over general operations often specialize in denial management, contract optimization, and pinpointing underpayments, as these areas can quickly boost revenue.

Claims management and denial management software are frequently sold together or as integrated modules from the same vendor. Some comprehensive claims management solutions may include robust denial management features, while in other cases, a specialized denial management tool might be integrated to provide more advanced capabilities. This integration allows for a more cohesive approach to the revenue cycle by aligning claims submission and denial resolution processes.

Recent AI and automation upgrades in claims management software

About 46% of healthcare systems now use AI in their RCM operations, as reported by AKASA/Healthcare Financial Management Association (HFMA) Pulse Survey. Those who don’t currently use it have plans to do so. In Waystar’s recent survey of 600 healthcare RCM, finance, and technology leaders, 92% state they will prioritize AI and advanced automation to overcome industry challenges in the coming year. 

AI is being integrated into various stages of the claims management process, offering sophisticated capabilities. These include: 

Generative AI applications

Generative AI is finding practical applications in claims management, such as generating appeal letters for denied claims and assisting with prior authorizations. The AHA shares that Banner Health uses a bot to automatically generate appeal letters based on specific denial codes. Huron Consulting Group, too, highlights the potential of generative AI and Robotic Process Automation (RPA) in transforming claims appeals.

Enhanced Patient Interaction

The AHA shares that AI can personalize payment plans based on patients’ financial situations. Further, AI-powered patient portals can offer personalized experiences, allowing patients to easily access billing information, understand payment options, and communicate with billing representatives. All of these features expedite payments. 

Predictive analytics and denial management

AI analyzes vast amounts of historical claims data to identify patterns and predict which claims are likely to be denied. This allows healthcare providers to proactively address potential issues before submission. Machine learning models continuously learn from new data, improving the accuracy of these predictions and helping to implement corrective actions to reduce future denials. As the AHA reports, some AI tools can flag claims likely to be denied based on historical payment data and payer adjudication rules, with documented success in reducing denials related to prior authorization and non-covered services.

Automation of core claims processes

AI-powered platforms are automating traditionally manual tasks such as claim submissions, tracking, and follow-ups. This reduces operational costs and frees up staff to focus on more complex issues or patient care. AI also assists in managing insurance verification and eligibility checks with greater accuracy, reducing rejections due to coverage errors.

Enhanced data analysis and insights

AI tools can process and analyze large datasets to identify trends, inefficiencies in billing and service delivery, and ensure compliance with billing regulations. This capability allows for proactive adjustments and helps fine-tune pricing strategies. When healthcare claims management software is trained on millions of unique claims, payment accuracy improves and administrative overhead decreases.  

Improved Accuracy and Error Reduction

Natural Language Processing (NLP) systems can automatically assign billing codes from clinical documentation, reducing manual effort and errors. Claim scrubbing functionalities powered by AI identify and correct errors in claims before they are submitted to payers. This move away from rigid rule-based approaches to a more dynamic, learning system translates into better accuracy and net revenue.   

These AI upgrades collectively aim to create a more efficient, accurate, and financially sound claims management process for healthcare providers.

7 ways healthcare claims management software improves revenue

Healthcare claims management software improves healthcare organization revenue through several key mechanisms:

• Automation and workflow optimization: By automating claims processing, billing, and eligibility verification, the software expedites reimbursement cycles, reduces manual errors, and minimizes repetitive administrative tasks. Following closely come faster payments, improved cash flow, and reassignment of staff to more complex, value-added activities.
• Reduction in claim denials and rework: Advanced claims management platforms use AI and analytics to identify and correct errors before claims are submitted, increasing the rate of “clean claims” and reducing costly denials and rework. With labor costs for claims status inquiries up 71% over the past five years, healthcare organizations must get those claims in correctly on the first pass. Predictive analytics also helps organizations proactively address issues that could lead to denials, further protecting revenue.
• Increased claims volume and efficiency: Automation enables organizations to process a larger volume of claims in less time. For example, robotic process automation can reduce the time to post payments from minutes to seconds per claim, as the most recent CAQH Index reports.  MGMA describes how one genetic testing company increased revenue by 24% after implementing healthcare claims management automation. This organization increased its appeals from 2,500 per week to 8,000. Its average appeals turnover rate rose from 30% to 41%, and turnaround on claims improved by 75%. Many other case studies report similar improvements.  
• Improved accounts receivable (A/R) and collections: By optimizing claim status tracking and automating follow-ups, organizations see reduced days in A/R and faster collections. When one Southeast academic medical center faced challenges with missing and delayed claim status responses due to their manual processes, they turned to automation. With the software implemented, the vice president of revenue cycle shared that they now enjoyed faster insurance collections, reduced accounts receivable aging, and decreased days in accounts receivable.
• Enhanced data accuracy and compliance: Integrated analytics and smart dashboards help track payer changes, reimbursement accuracy, and compliance with evolving regulations. These moves reduce the risk of financial penalties and support better decision-making.
• Better coordination of benefits and payment integrity: By using healthcare claims management software, providers coordinate benefits accurately before claims are paid, preventing incorrect payments. The increased payment integrity and cost avoidance stand to save large healthcare MSOs and physician groups millions. 
• Scalability and labor cost savings: Automated healthcare claims management reduces the need for additional staff as organizations grow, allowing them to handle increased business with minimal workforce expansion and lower operational costs.

Collectively, these improvements drive higher revenue, lower costs, and greater financial stability for healthcare organizations, while also supporting better patient and provider experiences.

Staff errors that healthcare claims management software catches

Claims management software is designed to catch a wide range of staff errors that commonly lead to claim denials, payment delays, and lost revenue. The most frequent errors detected and prevented by these systems include:

• Coding errors: Incorrect use of CPT, ICD, or HCPCS codes, including up-coding, under-coding, outdated codes, mismatched diagnosis and procedure codes, or missing/invalid modifiers.
  Missing or invalid information: Common omissions such as incomplete patient demographics (name, date of birth, insurance ID), provider details, or required documentation like referral forms and pre-authorization numbers. 
• Duplicate claims: Submitting the same claim multiple times, which can trigger fraud alerts and result in payment holds or denials.
• Lack of prior authorization: Failing to obtain or document prior authorization for services that require it, a leading cause of denials.
• Registration errors: Mistakes in patient registration, such as incorrect names, addresses, or insurance details can disrupt billing and cause rejections.
• Timeliness issues: Missing payer submission deadlines, leading to automatic denials. Software can track and alert staff to impending deadlines.
• Inappropriate unbundling or bundling of services: Incorrectly separating or combining services that should be billed together or apart according to payer rules.
• Failure to stay updated with coding changes: Using outdated codes or not complying with the latest payer requirements due to a lack of ongoing updates and training.
• Missing or invalid modifiers: Omitting or misapplying modifiers required for certain services, leading to denials.
• Poor follow-up practices: Not tracking claim status or failing to address rejections and denials promptly, resulting in lost revenue opportunities.

By automating the detection of these errors before claims are submitted, claims management software significantly increases first-pass acceptance rates, reduces administrative rework, and helps healthcare organizations achieve faster, more reliable reimbursement. 

Features of claims management software to insist upon

Here are the essential features to insist upon when selecting claims management software, as identified by leading industry sources:

• Automated workflows: Streamline repetitive tasks, assign claims automatically, and trigger alerts for pending actions to reduce processing time and human error.
• Denial workflow manager:  A denial workflow manager should include appeal generation and tracking workflows. Its workqueue feature should automatically distribute denied claims to the relevant team members based on customizable criteria (e.g., denial type, insurer, provider). Staff can mark appeal stages, add account labels, and create work queues for bulk process. This denial management feature should allow for the export of payer-ready data files for appeals as well. 
• Claims intake & registration: User-friendly interfaces for submitting and capturing claim details, including electronic First Notice of Loss (FNOL) and instant data validation.
• Document management: Centralized, digital storage and organization of all claim-related documents for easy access and retrieval.
• Integration capabilities: Seamless connectivity with EHRs, billing, CRM, policy administration, and other third-party systems for smooth data flow.
  Analytics & reporting: Advanced, customizable dashboards and real-time reporting to monitor performance, detect fraud, and support compliance.
• Customer and self-service portal: Secure online portals for patients or policyholders to submit, track, and manage claims independently.
• Fraud detection & risk assessment: AI-driven tools to identify suspicious claims, prevent overpayments, and reduce fraud risk.
• Payment Processing & Financial Management: Automated payment authorization, processing, co-pay/deductible tracking, and financial reconciliation.
• Customizable workflow & rules engine: Ability to tailor claim routing, approvals, and escalation based on organizational policies and claim complexity.
• Collaboration tools: Support for communication between staff, adjusters, and external partners, including notes, notifications, and integration with messaging platforms.
• Automated reminders & notifications: Multichannel alerts for deadlines, required actions, and claim status updates.
• Compliance management: Automated compliance checks and audit trails to ensure adherence to regulations and reduce the risk of penalties.
• Mobile access: Mobile-friendly interfaces for claim submission, status tracking, and workflow management on the go.
• Duplicate claim detection: Automated flagging and prevention of duplicate submissions.
• Role-based security: Granular access controls to ensure sensitive information is only available to authorized users.

Insisting on these features ensures your claims management software will drive efficiency, accuracy, compliance, and financial performance across your organization.

8 steps to integrate healthcare claims management software with your EHR

Integrating claims management software with an electronic health record (EHR) system is a multi-step process. Aim to create seamless data flow, improve accuracy, and optimize revenue cycle operations. Healthcare organizations typically achieve key integrations with these steps:

1. Assess system compatibility
   Begin by evaluating both the EHR and claims management software for compatibility. This includes ensuring both systems support industry standards like HL7 for data exchange, have robust APIs, and can meet security and compliance requirements.
2. Develop an integration plan
   Create a detailed plan outlining integration objectives, scope, data mapping, workflow adjustments, technical requirements, and a timeline. This plan should address which data and processes will be integrated, such as patient demographics, clinical notes, billing codes, and claims status updates.
3. Establish technical connectivity
   Use HL7 standards and APIs to enable communication between the EHR and claims management systems. Middleware may be used to translate data formats if the systems use different protocols. This step ensures real-time, accurate data transfer and interoperability.
4. Configure data mapping and transmission
   Map data fields between the EHR and claims software so that information like patient details, procedure codes, and insurance data transfers accurately. Set up the technical interface, including clearinghouse connection settings if claims are routed through a clearinghouse.
5. Implement and test the integration
   Install any necessary adapters or middleware, then conduct thorough testing using demo and real data. Verify that claims are correctly generated, transmitted, and received, and that reports flow back into the EHR. Testing should cover all workflows and security aspects.
6. Staff training and change management
   First, consider a change management plan to prepare employees for shifts in their workflow. Train staff on system features and troubleshooting. Comprehensive training ensures smooth adoption and minimizes errors during the transition.
7. Go live and monitor
   Launch the integrated system, starting with lower claim volumes and scaling up. Closely monitor performance, address any issues promptly, and optimize workflows based on real-time feedback.
8. Ongoing optimization
   Regularly review integration performance, update software as needed, refine data mapping, and provide ongoing staff training. Use analytics and reporting tools to identify and resolve recurring issues, ensuring continuous improvement.

This integration automates data transfer, reduces manual entry, improves claims accuracy, accelerates reimbursements, and enables real-time tracking and analytics—ultimately enhancing both operational efficiency and financial outcomes for healthcare providers.

Cost of healthcare claims management software

When considering the lost revenue from claim denials, the effort of resubmissions, and underpayments, avoiding healthcare claims management software often proves more costly than its implementation. 

The cost of healthcare claims management software can vary significantly based on several factors. Subscription models are common, with monthly fees for cloud-based solutions potentially influenced by the number of users, claim volume, or the scope of automated processes. 

While practices with higher claim volumes or more complex needs might face higher software costs, this investment is often offset by the significant returns from reduced errors, faster claim submissions, and improved reimbursement rates. The scalability of the software means costs can adjust as a practice's needs evolve.

Naturally, the specific features a practice requires will influence the overall cost. Basic claims processing features will be less expensive than a full suite that might include advanced analytics, AI-driven automation, robust denial management, underpayment recovery tools, or extensive workflow systems. Additional costs can also arise from customizations, design, specific security measures, ongoing maintenance (which can be 15-20% of the initial cost annually for on-premise systems), and cloud hosting.

When seeking healthcare claims management software, a practice should look for a vendor willing to thoroughly discuss its specific operational challenges, areas of lost revenue, and particular needs before finalizing discussions on costs and feature sets. This ensures the chosen solution provides a good return on investment. 

Healthcare claims management software – one path to earned revenue recapture

Automated claims software is no longer a luxury but a necessity in a complex healthcare landscape that’s increasingly moving towards greater automation. Leveraging AI and machine learning to handle data extraction, validation, and compliance helps ensure you can get your claims and denial work done without hiring additional staff.  

The claims management software features in MD Clarity’s RevFind automate and optimize the claims workflow. RevFind integrates with EHR systems, payer contracts, and fee schedules. With ClarityFlow, patients receive precise information about their financial responsibility before services are rendered, which increases upfront collections and reduces payment disputes.

Able to consolidate data from multiple EHR systems and payer contracts, RevFind helps raise claims accuracy and first-pass claims rate. Users enjoy higher clean claims submission rates and faster revenue capture. It also offers crucial financial clarity by enabling organizations to distinguish between claim denials and actual underpayments. It moves beyond manual spreadsheet management, delivering actionable, data-rich insights for continuous rate evaluation and tracking of contract performance. 

Schedule a demo to see how RevFind can help you achieve higher accuracy on your eligibility verifications so you can submit correct claims on first submission. 

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