At A Glance
Claims management is under pressure as payer changes, data errors and rising volumes drive denials and delays. This guide explains how automation and better data can improve accuracy, efficiency and reimbursement outcomes.
Key takeaways:
- Claims management is a critical component of the healthcare revenue cycle, directly affecting financial performance and operational efficiency.
- Increasing complexity across payers, regulations and patient responsibility is making claims management more challenging.
- Emerging technologies, including automation and artificial intelligence (AI), are reshaping how healthcare organizations manage claims and improve outcomes.
Claims management is one of the most pressing challenges in healthcare billing. According to Experian Health’s 2025 State of Claims survey, nearly half of providers had major concerns about whether or not payers would pay. If organizations cannot secure payment for the care they deliver, their entire mission is at risk.
The survey also suggests that barriers to on-time payment can arise at the earliest stages of the revenue cycle, in the form of incorrect or incomplete claims and patient registration information. Managing claims efficiently starts with the right data.
What is claims management in healthcare?
Claims management is the process of preparing, submitting and following up on healthcare claims, so providers are compensated for their services. It spans the entire revenue cycle, from verifying coverage during patient intake through final settlement.
How does claims management fit into the healthcare revenue cycle?
Good claims management keeps the rest of the revenue cycle on track. But the State of Claims survey suggests many providers are finding this increasingly tough.
| Key findings: |
| – 68% of providers say submitting “clean” claims is more challenging than a year ago |
| – 54% say claim errors are increasing |
| – 55% are spending more than 10 minutes re-running eligibility checks after incomplete results |
As it becomes harder to obtain and verify data, errors increase and clean claim rates take a dive. This diverts resources and attention from other revenue cycle tasks and forces staff to focus on paperwork instead of patients.
What are the key stages of the medical claims lifecycle?
Each of the following steps is a chance to keep the claim moving:
Patient intake and verification
Staff collect and verify patient demographic information, insurance details and eligibility at patient intake. If crucial data is missed, a denial is likely. Patient Access Curator™ (PAC) addresses this directly, using AI and robotic process automation to automatically check and verify these details.
Watch the video: Exact Sciences fixes front-end data with Patient Access Curator
Medical coding
Coding is where clinical services become billable. Coding staff assigns standardized diagnosis, procedure and supply codes from thousands of possible options. If the codes don’t match the care provided or if required modifiers are left out, the claim may be denied, leaving money on the table.
Claim submission
Next, all the key data is packaged and sent to the payer, often through a clearinghouse. Claims should be reviewed line by line before filing, which is risky when relying solely on manual processes. Automation offers a better chance at avoiding claim errors before they reach the payer.
Adjudication and payment posting
Once the payer reviews the claim, they’ll validate the services, apply negotiated rates and determine payment or denial. Payment posting closes the loop, enabling providers to quickly reconcile accounts and flag underpayments that require further action.
Denial management and appeals
Not every claim gets paid the first time. A CBS News analysis found that in 2024, around one in five claims were denied. When denials come in, teams need to know what went wrong so they can fix the issue and resubmit the claim quickly. Denial management software identifies the reasons for claim denials and organizes work queues for faster resolution.
Patient billing and collections
Anything insurance doesn’t cover is billed to the patient. If the bill is confusing or shows up late, it’s less likely to be paid. Upfront conversations, flexible payment options and convenient point-of-service collections can improve collection rates and patient satisfaction.
Why is claims management becoming more complex?
Claims management is becoming increasingly complex as payer policies evolve and coding requirements continuously change. Payers are also using AI and automation to review and process claims much faster, while patient coverage frequently shifts as individuals move between health plans. Although recent data shows that more appeals are being approved, the appeals process remains costly and time-intensive – making it critical for providers to reduce denials upfront.
Providers that continue to rely on a fragmented, manual healthcare claims process will struggle to keep up.
Best practices for effective claims management
Getting ahead of the claims challenge isn’t just about fixing denials after the fact, but about preventing them in the first place. Here are a few places to start:
Implementing automation and technology
Automation helps standardize repetitive tasks, reduce errors and create a consistent claims processing workflow that can handle sudden surges in patient volumes. AI takes this to the next level by predicting denials, flagging coding errors or coverage issues before submission, and prioritizing claims that need attention.
| Some examples: |
| Patient Access Curator uses AI and automation to check and correct patient insurance details through a single interface, giving staff more accurate data in real-time. |
| ClaimSource® organizes claims activity from a single hub. This automated system makes claims editing and submissions more efficient, by performing customizable edits and checking for errors before submission. |
| On the back end, AI Advantage™ uses AI and machine learning to predict claim outcomes and pushes urgent tasks to the front of the queue, so staff can spend time on the claims that matter most financially. |
Training and education for staff
Staff should undergo regular training to stay current on payer rules, policy changes, coding updates and new technology. Experian Health offers live training and on-demand webinars for teams to hear about the latest industry best practices and see how others are using different tools. Hands-on consultancy support is also available to help teams get up and running with claims management products.
Monitoring and analyzing claims data
Staff also need to be able to see where claims might be getting stuck. Tracking key performance indicators like clean claim rate, denial rate and days in accounts receivable helps staff spot issues. Integrated revenue cycle management tools bring everything together in one place so management can see the full picture and make sense of their data.
Common challenges in claims management and how to overcome them
Even with best practices in place, there will always be challenges. Claims pass through multiple departments, creating multiple opportunities for miscommunication or mistakes. Aligning workflows reduces friction and helps keep data secure.
Another hurdle is managing the growing number of tools in use. The 2025 State of Claims report shows that 81% of providers use multiple tools to collect patient information needed for a claim submission. This fragmented approach often creates inefficiencies, duplicate work and inconsistent workflows. Consolidating claims management software with a single vendor can help streamline operations and create a more efficient end-to-end process.
Why claims management remains a strategic priority for healthcare leaders
Claims management will always be a strategic priority because it ties together two of the most important aspects of healthcare delivery: patient care and cash flow. It determines how reliably organizations convert care into revenue and how many dollars are lost to inefficiency. The impact goes beyond the balance sheet, directly affecting patient satisfaction and operational efficiency.
Next steps for strengthening your claims management approach
| Healthcare leaders should ask: |
| – Are denial trends being tracked and addressed? |
| – Do teams have the tools and training they need? |
| – Is automation being used where it can make the most significant difference? |
Answering “yes” to these questions is the first step toward efficient claims management and moving from daily firefighting to predictable reimbursement strategies.
FAQs
Technology is changing the role of claims management in revenue cycle operations from reactive to proactive. Experian Health’s claims management software uses automation and AI to catch errors earlier, while prioritizing high-risk claims and reducing the cycle of delays and denials.
Claims management matters because providers are stuck in a cycle of denials and delays. More than four in ten organizations see at least one in ten claims being denied. Denials mean lost revenue, but delays carry a cost too, as extra rework eats away at revenue even if payment eventually comes through.
Future claims management strategies should focus on improving front-end data accuracy. Once bad data enters the system, every subsequent action wastes resources. Patient Access Curator was created to prevent and address this.
Find out more about how Experian Health’s award-winning claims management solutions help healthcare providers improve reimbursement rates and reduce denials.
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