# Claims Processing * **Definition:** The administrative process of managing, evaluating, and adjudicating healthcare claims submitted by providers to payers or insurance companies for reimbursement of services rendered. * **Taxonomy:** CTO Topics / Claims Processing ## News * Selected news on the topic of **Claims Processing**, for healthcare technology leaders * 3.6K news items are in the system for this topic * Posts have been filtered for tech and healthcare-related keywords | Date | Title | Source | | --- | --- | --- | | 5/23/2025 | [**Ethical Governance in Generative AI for Insurance - by OCTAVE - John Keells Group**](https://medium.com/@octave-jkh/ethical-governance-in-generative-ai-for-insurance-e1d12a97c037) | [[Medium]] | | 5/19/2025 | [**Oracle, Cleveland Clinic, G42 collaborate on AI platform - Healthcare Finance News**](https://www.healthcarefinancenews.com/news/oracle-cleveland-clinic-g42-collaborate-ai-platform) | [[Healthcare Finance]] | | 5/14/2025 | [**Automation in Healthcare Claims Processing: A Practical Guide - by Klippa - Medium**](https://medium.com/@Klippa/automation-in-healthcare-claims-processing-a-practical-guide-3144a79890b9) | [[Medium]] | | 4/28/2025 | [**Claims Processing Software Market Tech Scope & Strategic Trends - LinkedIn**](https://www.linkedin.com/pulse/claims-processing-software-market-tech-scope-strategic-p5ole) | [[Linkedin]] | | 4/28/2025 | [**AI In Healthcare Market Size to Reach $187.7 Billion by 2030 at CAGR 38.5**](https://finance.yahoo.com/news/ai-healthcare-market-size-reach-140500267.html) | [[Yahoo Finance]] | | 4/19/2025 | [**HIMSS Changemaker recommends investing time to mentor - Healthcare Finance News**](https://www.healthcarefinancenews.com/video/changemaker-recommends-investing-time-mentor) | [[Healthcare Finance]] | | 4/10/2025 | [**Google Cloud healthcare agentic AI and AI transformation solutions - PwC**](https://www.pwc.com/us/en/technology/alliances/google-cloud/healthcare-ai-agents-solutions.html) | [[PWC]] | | 4/7/2025 | [**AI helps reduce billing errors, but integration challenges loom - Healthcare IT News**](https://www.healthcareitnews.com/news/ai-helps-reduce-billing-errors-integration-challenges-loom) | [[Healthcare IT News]] | | 3/2/2025 | [**Transformative Technologies Reshaping the Healthcare Industry - by Reza Lankarani**](https://medium.com/@RezaLankarani/transformative-technologies-reshaping-the-healthcare-industry-cc72b937b8ec) | [[Medium]] | | 2/28/2025 | [**The Home Care Tipping Point: Why 2025 Could Break or Make Your Business - LinkedIn**](https://www.linkedin.com/pulse/home-care-tipping-point-why-2025-could-break-make-your-iqhvc) | [[Linkedin]] | | 1/29/2025 | [**LLMs in Healthcare: A Measured Path to Impact**](https://www.healthcareittoday.com/2025/01/29/llms-in-healthcare-a-measured-path-to-impact/) | [[Healthcare IT Today]] | | 12/13/2024 | [**A safety-net hospital CFO gets real about AI, cybersecurity spend**](https://www.beckershospitalreview.com/finance/a-safety-net-hospital-cfo-gets-real-about-ai-cybersecurity-spend.html) | [[Beckers Hospital Review]] | | 11/27/2024 | [**Comprehensive Examination of the Healthcare Software As A Service Market - LinkedIn**](https://www.linkedin.com/pulse/comprehensive-examination-healthcare-software-service-bpitc) | [[Linkedin]] | | 10/17/2024 | [**Healthcare Payer Services Business Research Report 2023-2024 & 2030 - Growth in Telehealth and Virtual Care Services Expands the Scope of Payer Services - ResearchAndMarkets.com**](http://www.businesswire.com/news/home/20241017425707/en/Healthcare-Payer-Services-Business-Research-Report-2023-2024-2030---Growth-in-Telehealth-and-Virtual-Care-Services-Expands-the-Scope-of-Payer-Services---ResearchAndMarkets.com/?feedref=JjAwJuNHiystnCoBq_hl-RLXHJgazfQJNuOVHefdHP-D8R-QU5o2AvY8bhI9uvWSD8DYIYv4TIC1g1u0AKcacnnViVjtb72bOP4-4nHK5ieT3WxPE8m_kWI77F87CseT) | [[Business Wire]] | | 10/17/2024 | [**Healthcare Payer Services Business Research Report 2023-2024 & 2030 - Growth in Telehealth and Virtual Care Services Expands the Scope of Payer Services - ResearchAndMarkets.com**](http://www.businesswire.com/news/home/20241017425707/en/Healthcare-Payer-Services-Business-Research-Report-2023-2024-2030---Growth-in-Telehealth-and-Virtual-Care-Services-Expands-the-Scope-of-Payer-Services---ResearchAndMarkets.com/?feedref=JjAwJuNHiystnCoBq_hl-Q-tiwWZwkcswR1UZtV7eGe24xL9TZOyQUMS3J72mJlQ7fxFuNFTHSunhvli30RlBNXya2izy9YOgHlBiZQk2LOzmn6JePCpHPCiYGaEx4DL1Rq8pNwkf3AarimpDzQGuQ==) | [[Business Wire]] | | 10/15/2024 | [**Healthcare EDI Market to Hit USD 7.11 Billion by 2029 with 9.7AGR - PR Newswire**](https://www.prnewswire.com/news-releases/healthcare-edi-market-to-hit-usd-7-11-billion-by-2029-with-9-7-cagr--marketsandmarkets-302276018.html) | [[PR Newswire]] | | 10/10/2024 | [**Healthcare Payer Services Business Research Report 2024: Global Market to Surpass $100 ...**](https://finance.yahoo.com/news/healthcare-payer-services-business-research-141400536.html) | [[Yahoo Finance]] | | 9/25/2024 | [**Is AI helping or hurting rural healthcare?**](https://www.beckershospitalreview.com/healthcare-information-technology/is-ai-helping-or-hurting-rural-healthcare.html) | [[Beckers Hospital Review]] | | 9/20/2024 | [**Hospitals desire a digitalized revenue cycle, but challenges persist**](https://www.beckershospitalreview.com/finance/hospitals-desire-a-digitalized-revenue-cycle-but-challenges-persist.html) | [[Beckers Hospital Review]] | | 9/17/2024 | [**Survey: Payers, Providers Boosting IT Investments - Healthcare Innovation**](https://www.hcinnovationgroup.com/finance-revenue-cycle/health-it-market/news/55140397/survey-payers-providers-boosting-it-investments) | [[Healthcare Innovation]] | | 7/20/2024 | [**Healthcare Business Process Outsourcing (BPO) Market size is set to grow by USD ... - PR Newswire**](https://www.prnewswire.com/news-releases/healthcare-business-process-outsourcing-bpo-market-size-is-set-to-grow-by-usd-17-29-billion-from-2024-2028--focus-on-reducing-operational-costs-to-boost-the-market-growth-technavio-302200687.html) | [[PR Newswire]] | | 7/16/2024 | [**Claims Processing Outsourcing India: Cynergy BPO on CX, Operating Efficiency, and Compliance**](https://insurance-edge.net/2024/07/16/claims-processing-outsourcing-india-cynergy-bpo-on-cx-operating-efficiency-and-compliance/) | insurance-edge.net | | 7/16/2024 | [**United States Healthcare BPO Market Advancements Highlighted by Report Analysis, Size ...**](https://www.whatech.com/og/markets-research/medical/857204-united-states-healthcare-bpo-market-report-analysis-size-share-2024-32) | whatech.com | | 7/10/2024 | [**Healthcare BPO Market: $395.3B to $626.6B Growth Forecast (2024-2029) - MarketsandMarkets™**](https://www.globenewswire.com/news-release/2024/07/10/2911104/0/en/Healthcare-BPO-Market-395-3B-to-626-6B-Growth-Forecast-2024-2029-MarketsandMarkets.html) | [[Globe Newswire]] | | 6/17/2024 | [**Healthcare BPO Market Anticipates USD 626.6 Billion by 2029 with 9.7% CAGR - MarketsandMarketstm**](https://www.lelezard.com/en/news-21422134.html) | lelezard.com | ## Topic Overview (Some LLM-derived content — please confirm with above primary sources) ### Key Players - **Med Claims Compliance**: Pioneering a hybrid AI approach to improve claims processing accuracy and reduce administrative burdens. - **Accenture**: A leading global professional services company that provides comprehensive solutions in claims processing and revenue cycle management. - **Judi Health**: The first Unified Claims Processing platform that integrates pharmacy and medical benefits to enhance healthcare experience. - **Cognizant**: A multinational technology company that focuses on modernizing administrative systems and enhancing claims processing efficiency. - **Thoughtful AI**: Developed AI Agents for streamlining revenue cycle management tasks, including claims processing and eligibility verification. - **Effective Health Systems**: Introduced BaseLine.RPT, an AI-powered solution to automate claims processing in the workers' compensation industry. - **Capital Rx**: Introduced Judi Health™, a unified claim processing platform that integrates pharmacy and medical claims administration. - **Qantev**: An AI-powered claims platform that automates the claims process, reducing processing time significantly and saving insurers operational costs. - **Change Healthcare**: A subsidiary of UnitedHealth Group that faced a cyberattack impacting claims processing but has since restored services. - **Med Claims Compliance Corporation (MCC)**: A company demonstrating AI-enabled clinical documentation and claims processing technology to improve efficiency. - **Acentra Health**: Recognized for its innovative use of cloud-native solutions to enhance claims processing efficiency. - **Cotiviti**: A healthcare analytics company that focuses on improving claims processing and reducing administrative costs through data-driven solutions. - **Prudential**: An insurance company leveraging AI and cloud technology to enhance claims processing and personalize healthcare journeys. ### Partnerships and Collaborations - **Med Claims Compliance**: Integrates AI technology with human oversight to enhance accuracy in claims processing and reduce administrative burdens. - **Scalapay and Trustfull**: Collaboration aimed at improving fraud prevention in claims processing. - **Agentech and Odie**: A partnership focused on enhancing claims processing efficiency. - **Acentra Health and Washington State**: First to move a Medicaid Enterprise System to the cloud, showcasing technological leadership in claims processing. - **Prudential and Google Cloud**: Partnered to enhance claims processing using AI models tailored for healthcare. - **MCC and Congressman Jack Bergman**: Demonstrated AI-enabled claims processing technology to improve healthcare efficiency. - **Novo AI and First Round Capital**: Novo AI is supported by First Round Capital to develop AI tools aimed at optimizing claims processing and reducing denial rates. - **IGT Solutions and AuxoAI**: Formed a strategic partnership to enhance productivity in claims processing within the Travel, Transportation, and Hospitality industry. - **Thoughtful AI and Healthcare Providers**: Thoughtful AI collaborates with healthcare providers to implement AI Agents that automate revenue cycle management tasks, significantly reducing claim denials and improving processing speed. - **Cotiviti and Edifecs**: Cotiviti acquired Edifecs to enhance interoperability and streamline healthcare operations, improving claims processing. - **HealthEdge and Healthcare Executives**: HealthEdge conducts annual surveys with healthcare executives to identify priorities and challenges in claims processing and revenue cycle management. - **Acentra Health and AWS**: Acentra Health has been recognized as an AWS Champion for its innovative cloud solutions that enhance claims processing and public health outcomes. - **Xsolis and Beacon Health System**: This partnership has improved administrative processes and claims management, allowing for increased patient support despite staffing challenges. - **Accenture Federal Services and Red River**: Supporting the U.S. Army's migration to Oracle's cloud for improved HR and payroll operations. - **Netsmart and Arisa Health**: A partnership aimed at implementing the CareFabric platform to improve clinical, financial, and operational efficiencies in behavioral health services. - **Oracle, Cleveland Clinic, and G42**: These organizations partnered to create an AI-based healthcare delivery platform aimed at enhancing care and public health management. - **AWS and Acentra Health**: Acentra Health's recognition as an AWS Champion highlights its collaboration with AWS to enhance public health outcomes. - **athenahealth and SoNE HEALTH**: SoNE HEALTH is implementing athenaOne to enhance care coordination and operational efficiency, driving growth and improving patient care. ### Innovations, Trends, and Initiatives - **Mobile-First Claims Processing**: The rise of mobile-first systems is enhancing user experience by enabling faster claim submissions and real-time tracking. - **AI-Powered Claims Processing**: Utilization of AI to enhance efficiency, transparency, and patient empowerment in claims processing. - **AI in Claims Processing**: AI is being integrated into claims processing to improve efficiency, accuracy, and reduce administrative burdens. - **Automation Solutions**: Technologies like AI-powered Optical Character Recognition (OCR) and Intelligent Document Processing (IDP) are streamlining claims workflows. - **AI and Automation in Claims Processing**: The integration of AI and automation technologies is transforming claims processing by enhancing efficiency, reducing errors, and improving decision-making. - **AI Integration**: The integration of AI, machine learning, and robotic process automation into claims processing is enhancing efficiency and accuracy. - **Healthcare BPO Services**: Outsourcing of claims processing and administrative tasks to specialized providers to improve operational efficiency. - **Thoughtful AI's Agents**: New AI agents designed to automate claims processing, patient eligibility verification, and payment posting. - **Cloud-Based Solutions**: The adoption of cloud-based services is driving efficiency in claims processing, allowing for better scalability and integration with healthcare systems. - **BaseLine.RPT**: An AI-powered solution designed to enhance claims processing efficiency in the workers' compensation industry. - **Judi Health™ by Capital Rx**: A platform that centralizes claim processing to address inefficiencies in the U.S. healthcare system. - **Cloud Computing Adoption**: Healthcare organizations are adopting cloud solutions for Business Process Outsourcing (BPO) to improve claims processing efficiency. - **Clinical Data Exchange by Oracle**: A new platform designed to streamline claims processing through automated data exchange, reducing reliance on manual methods. - **CDA Exchange+ by Smile Digital Health**: A solution designed to improve claims processing accuracy for payers by transforming various CDA document types. - **Medical Claims Management Solutions Market Growth**: The market is projected to grow at a CAGR of 8.5% from 2024 to 2031, driven by the increasing need for automated claims processing systems. ### Challenges and Concerns - **Data Privacy Issues**: Concerns regarding the handling of sensitive patient information during claims processing. - **Complexity of Claims Processing**: Healthcare providers face challenges in navigating complex claims processes, particularly with Veterans Administration claims, which can hinder timely access to care. - **Claims Denials and Errors**: Healthcare providers face high claim denial rates and billing errors, often due to miscommunications and lack of prior authorizations, leading to significant financial burdens. - **Claims Denials**: Healthcare providers are experiencing increased struggles with claims denials, primarily due to prior authorizations and inaccurate data. - **Regulatory Compliance**: Challenges in adhering to healthcare regulations while optimizing claims processing through BPO services. - **Administrative Burdens**: Healthcare workers spend significant time correcting billing errors, highlighting the inefficiencies in current claims processing systems. - **Cybersecurity Threats**: Recent cyberattacks have raised concerns about data security and the integrity of claims processing systems. - **Cybersecurity Risks**: Recent cyber-attacks have highlighted vulnerabilities in claims processing systems, emphasizing the need for robust cybersecurity measures to protect sensitive data. - **Data Management Issues**: Fragmented data ecosystems and unstructured data complicate claims processing and hinder operational efficiency. - **Claims Denials and Delays**: High rates of claims denials and delays contribute to financial losses and staff burnout in healthcare organizations. - **Outdated Payment Systems**: Many healthcare organizations struggle with outdated claims processing systems, leading to inefficiencies, increased denial rates, and financial instability. - **Complexity of Healthcare Reimbursement**: The increasing complexity of reimbursement models necessitates advanced payer services to manage claims effectively. - **Staffing Shortages**: The healthcare industry is experiencing burnout and inefficiencies due to staffing shortages, impacting claims processing and administrative tasks. ## Related Topics [[Claims Management]]; [[Claims Reviews]]; [[Claims Denials]]