# Claims Reviews * **Definition:** Claims Reviews refer to the process of evaluating and analyzing healthcare claims submitted by providers to insurance companies or payers to ensure accuracy, compliance with regulations, and appropriateness of services billed. This process often involves verifying the legitimacy of the claims, assessing the medical necessity of the services provided, and identifying any discrepancies or potential fraud. * **Taxonomy:** Healthcare Topics / Claims Reviews ## News * Selected news on the topic of **Claims Reviews**, for healthcare technology leaders * 950 news items are in the system for this topic * Posts have been filtered for tech and healthcare-related keywords | Date | Title | Source | | --- | --- | --- | | 5/15/2025 | [**AI In Life Science Analytics Market Size to reach $3.6 billion, Globally, by 2030 - Exclusive Research by The Research Insights**](https://www.prnewswire.com/news-releases/ai-in-life-science-analytics-market-size-to-reach-3-6-billion-globally-by-2030---exclusive-research-by-the-research-insights-302456530.html) | [[PR Newswire]] | | 5/15/2025 | [**AI In Life Science Analytics Market Size to reach $3.6 billion, Globally, by 2030**](https://finance.yahoo.com/news/ai-life-science-analytics-market-151600164.html) | [[Yahoo Finance]] | | 5/2/2025 | [**Life Science Analytics Market worth $68.81 billion by 2030 11.4AGR - MarketsandMarkets™**](https://www.prnewswire.com/news-releases/life-science-analytics-market-worth-68-81-billion-by-2030-11-4-cagr--marketsandmarkets-302444901.html) | [[PR Newswire]] | | 4/30/2025 | [**Women's Health IT and Software Innovations Undergo Rapid Expansion: Black Book ...**](https://finance.yahoo.com/news/womens-health-software-innovations-undergo-150000654.html) | [[Yahoo Finance]] | | 2/24/2025 | [**Demystifying AI in healthcare: From innovation to implementation**](https://www.healthcaredive.com/spons/demystifying-ai-in-healthcare-from-innovation-to-implementation/736625/) | [[Healthcare Dive]] | | 2/5/2025 | [**Healthcare Smart Contracts Global Strategic Business Report 2025 with Coverage of 40+ Players Including Aetsoft, Apriorit, burstIQ, Debut Infotech, ELEKS, Hedera Hashgraph, IBM, Microsoft, OpenXcell - ResearchAndMarkets.com**](http://www.businesswire.com/news/home/20250205620015/en/Healthcare-Smart-Contracts-Global-Strategic-Business-Report-2025-with-Coverage-of-40-Players-Including-Aetsoft-Apriorit-burstIQ-Debut-Infotech-ELEKS-Hedera-Hashgraph-IBM-Microsoft-OpenXcell---ResearchAndMarkets.com/?feedref=JjAwJuNHiystnCoBq_hl-RLXHJgazfQJNuOVHefdHP-D8R-QU5o2AvY8bhI9uvWSD8DYIYv4TIC1g1u0AKcacnnViVjtb72bOP4-4nHK5ieT3WxPE8m_kWI77F87CseT) | [[Business Wire]] | | 2/5/2025 | [**Healthcare Smart Contracts Global Strategic Business Report 2025 with Coverage of 40+ Players Including Aetsoft, Apriorit, burstIQ, Debut Infotech, ELEKS, Hedera Hashgraph, IBM, Microsoft, OpenXcell - ResearchAndMarkets.com**](http://www.businesswire.com/news/home/20250205620015/en/Healthcare-Smart-Contracts-Global-Strategic-Business-Report-2025-with-Coverage-of-40-Players-Including-Aetsoft-Apriorit-burstIQ-Debut-Infotech-ELEKS-Hedera-Hashgraph-IBM-Microsoft-OpenXcell---ResearchAndMarkets.com/?feedref=JjAwJuNHiystnCoBq_hl-Q-tiwWZwkcswR1UZtV7eGe24xL9TZOyQUMS3J72mJlQ7fxFuNFTHSunhvli30RlBNXya2izy9YOgHlBiZQk2LOzmn6JePCpHPCiYGaEx4DL1Rq8pNwkf3AarimpDzQGuQ==) | [[Business Wire]] | | 2/3/2025 | [**Harnessing AI to Transform Urgent Care Centers: Improving Efficiency, Morale, and Profitability**](https://www.healthcareittoday.com/2025/02/03/harnessing-ai-to-transform-urgent-care-centers-improving-efficiency-morale-and-profitability/) | [[Healthcare IT Today]] | | 1/31/2025 | [**Arcadia Named #1 in Healthcare Data Governance and Analytics in the 2025 Black Book ...**](https://finance.yahoo.com/news/arcadia-named-1-healthcare-data-183000182.html) | [[Yahoo Finance]] | | 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]] | | 1/29/2025 | [**U.S. Revenue Cycle Management Market Insights, 2024 and 2025-2030 with Change Healthcare, Epic Systems, Experian, McKesson, Oracle, R1 RCM, Veradigm, and SSI Dominating - ResearchAndMarkets.com**](http://www.businesswire.com/news/home/20250129051735/en/U.S.-Revenue-Cycle-Management-Market-Insights-2024-and-2025-2030-with-Change-Healthcare-Epic-Systems-Experian-McKesson-Oracle-R1-RCM-Veradigm-and-SSI-Dominating---ResearchAndMarkets.com/?feedref=JjAwJuNHiystnCoBq_hl-RLXHJgazfQJNuOVHefdHP-D8R-QU5o2AvY8bhI9uvWSD8DYIYv4TIC1g1u0AKcacnnViVjtb72bOP4-4nHK5ieT3WxPE8m_kWI77F87CseT) | [[Business Wire]] | | 1/13/2025 | [**Sun Knowledge Inc. Gears Up for the Launch of Its Revolutionary SDP Platform**](http://prsync.com/sun-knowledge/sun-knowledge-inc-gears-up-for-the-launch-of-its-revolutionary-sdp-platform--4552264/) | [[PRSync]] | | 12/10/2024 | [**4 Cornerstones for Successful AI Implementation in Hospital Revenue Cycle Management in 2025**](https://hitconsultant.net/2024/12/10/4-cornerstones-for-successful-ai-implementation-in-hospital-revenue-cycle-management/) | [[HIT Consultant]] | | 12/9/2024 | [**Medical Billing Challenges: How Healthcare AI Helps Navigate Claim Denials**](https://www.healthitanswers.net/medical-billing-challenges-how-healthcare-ai-helps-navigate-claim-denials/) | [[Health IT Answers]] | | 11/12/2024 | [**Aspirion Appoints Nick Giannasi as Chief Executive Officer**](https://finance.yahoo.com/news/aspirion-appoints-nick-giannasi-chief-150000601.html) | [[Yahoo Finance]] | | 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]] | | 10/10/2024 | [**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]] | | 7/26/2024 | [**Medical Billing Market: $16.8B to $27.7B Growth Forecast (2024-2029) - MarketsandMarkets™**](https://www.globenewswire.com/news-release/2024/07/26/2919552/0/en/Medical-Billing-Market-16-8B-to-27-7B-Growth-Forecast-2024-2029-MarketsandMarkets.html) | [[Globe Newswire]] | | 7/19/2024 | [**Healthcare Business Process Outsourcing (BPO) Market size is set to grow by USD 17.29 ...**](https://finance.yahoo.com/news/healthcare-business-process-outsourcing-bpo-215000196.html) | [[Yahoo Finance]] | | 7/19/2024 | [**Healthcare Business Process Outsourcing (BPO) Market size is set to grow by USD ... - Le Lézard**](https://www.lelezard.com/en/news-21458986.html) | lelezard.com | | 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 | | 6/19/2021 | [**HealthLeaders Podcast**](https://www.healthleadersmedia.com/podcast-type/healthleaders-podcast) | [[HealthLeaders Media]] | ## Topic Overview (Some LLM-derived content — please confirm with above primary sources) ### Key Players - **ServiceNow**: A cloud-based platform recognized for its capabilities in claims management and operational optimization. - **VoiceCare AI**: A startup that utilizes generative AI technology to automate healthcare administration tasks, including claims processing. - **Bluespine**: An AI-driven claims cost reduction platform that helps self-insured employers tackle healthcare overspending and medical overbilling. - **Thoughtful AI**: An AI-powered revenue cycle automation company that has developed AI Agents to streamline claims processing and reduce costs. - **Iodine Software**: A company that has launched an Appeals Management Workspace to automate denial management processes and improve revenue cycle efficiency. - **NovoDynamics**: A healthcare technology company specializing in AI-driven dental insurance claim review technology. - **Pieces**: A Dallas health AI company accused of making false claims about its generative AI technology used in hospitals. - **Red Sky Health**: A startup focused on optimizing healthcare claims management using AI technology. - **Tassat Group**: A company leveraging blockchain technology to improve healthcare claims and payment processes. - **Conduent**: A leader in healthcare payer operational transformation, processing over one billion healthcare claims annually. - **HiLabs**: A company recognized for its use of Generative AI to enhance healthcare payer operations and streamline claims management. - **Black Book Research**: A research firm that evaluates AI applications in revenue cycle management and provides insights on industry trends. - **eClinicalWorks**: The largest ambulatory cloud EHR provider, known for its revenue cycle management solutions. - **CareJourney**: A provider of healthcare data and analytics that specializes in Medicare and Medicaid data analysis. - **EnableComp**: A company recognized for its technology-driven solutions that enhance revenue cycle performance for healthcare organizations. - **Humata Health**: A startup focused on improving the prior authorization experience for healthcare payers and providers using AI technology. - **Corti**: An AI technology provider focused on enhancing healthcare operations through medical coding solutions. - **Arcadia**: A healthcare data platform company that has acquired CareJourney to enhance its value-based care analytics capabilities. ### Partnerships and Collaborations - **Valer and Clearwave**: A strategic partnership aimed at automating prior authorizations and enhancing patient intake experiences to reduce administrative burdens. - **Tassat Group and Veuu**: A partnership aimed at improving claims and payment processes using private permissioned blockchain technology. - **Humata Health Funding**: Secured $25 million in funding led by Blue Venture Fund and LRVHealth to enhance prior authorization processes. - **Tanner Health and Healthliant Ventures with Corti**: A strategic partnership to enhance healthcare operations in Georgia and Alabama through AI-driven medical coding solutions. - **Net Health and Alinea Engage**: Net Health acquired Alinea Engage to improve patient engagement and streamline administrative processes. - **Prudential and Google Cloud**: Collaboration to enhance internal processes and customer interactions through AI applications. - **Bluespine and Major Employers**: Bluespine is partnering with major employers like Mattel and Alliant Insurance Services to address healthcare overspending. - **Novartis and Generate**: Biomedicines: Novartis has partnered with Generate:Biomedicines, which utilizes AI for drug development. ### Innovations, Trends, and Initiatives - **AI in Claims Reviews**: AI technology is being utilized to screen medical claims for fraud, waste, and abuse, with studies indicating significant cost recoveries. - **Automation in Claims Processing**: Technological advancements are leading to the development of platforms that automate claims scrubbing and eligibility verification. - **AI in Claims Management**: Healthcare providers are increasingly adopting AI to analyze denial patterns and improve billing accuracy, leading to higher patient satisfaction. - **AI-Driven Technologies**: Companies like NovoDynamics and Red Sky Health are utilizing AI to enhance claim review processes and reduce denials. - **Claims Cost Reduction Technology**: Bluespine's platform analyzes 100% of claims using AI technology to identify and prevent overbilled claims. - **Automation in Appeals Management**: Iodine Software launched its Appeals Management Workspace to automate appeal letter generation and denial tracking. - **AI Agents by Thoughtful AI**: A suite of AI Agents designed to automate tasks in revenue cycle management, significantly improving processing speed and reducing claim denials. - **AI-Driven Automation**: The implementation of AI in healthcare is leading to reduced claim denials and improved operational efficiency, with reports indicating up to 75% reduction in denials. - **Healthcare Smart Contracts**: Blockchain-based solutions aimed at automating claims processing and enhancing data interoperability in healthcare. - **Generative AI in Claims Processing**: Nym is exploring the use of large language models to automate insurance claims processing and improve operational efficiency. - **Blockchain Integration**: Tassat Group's use of blockchain technology aims to improve traceability and security in claims processing. - **Generative AI and Machine Learning**: These technologies are being leveraged to streamline claims processes by analyzing historical data and automating manual tasks. - **Automation in RCM**: Athenahealth's innovations in automating revenue cycle management processes are designed to reduce administrative burdens and improve efficiency. - **Healthcare Denial Management Market Growth**: Projected to grow significantly, driven by the need for advanced denial management solutions and the integration of AI technologies. - **Human-in-the-Loop Machine Learning**: MCC is implementing HITL/ML approaches to ensure accuracy in medical coding and documentation. - **Generative AI in RCM**: Generative AI is being utilized to automate routine tasks in revenue cycle management, improving efficiency and reducing costs. ### Challenges and Concerns - **Rising Claims Denials**: Claims denials have increased significantly, with a reported rise of 20.2% for commercial plans and 55.7% for Medicare Advantage plans, leading to financial burdens on providers. - **Insurance Claim Denials**: The healthcare industry faces significant challenges with high rates of claim denials, impacting financial stability. - **High Claim Denial Rates**: Healthcare providers are facing increasing claim denials, leading to financial strain and necessitating improved revenue cycle processes. - **Regulatory Compliance**: Healthcare organizations must navigate complex regulatory environments, which can complicate claims management. - **Data Privacy**: Concerns regarding data privacy and security, especially with the integration of technologies like facial recognition in claims processing. - **Complexity of VA Claims**: Providers struggle with navigating Veterans Administration claims due to complex eligibility requirements and stringent documentation demands. - **AI-Driven Denials**: Concerns about the use of AI in claims processing include potential discrimination and bias, as well as the impact of automated denials on patient care. - **Workforce Shortages**: The anticipated loss of experienced staff in healthcare is exacerbating issues related to claims processing and administrative burdens. - **Medical Billing Inaccuracies**: Studies show that 80% of medical bills contain errors, primarily due to incorrect coding, leading to significant financial discrepancies. - **Administrative Costs**: Administrative costs now represent over 40% of hospitals' total expenses, largely due to increased care denials linked to AI tools. - **AI Hallucinations**: The issue of AI hallucinations poses risks in healthcare, potentially leading to false data generation and misinterpretations. - **Data Security**: The need for robust cybersecurity measures in healthcare BPO to protect patient confidentiality and comply with regulations. - **Hidden Costs of Outsourcing**: Healthcare organizations must manage hidden costs associated with outsourcing to maximize value and minimize financial risks. - **Cybersecurity Risks**: The integration of AI in healthcare poses significant cybersecurity risks, as cybercriminals target sensitive patient data. - **Labor Shortages**: Healthcare providers face challenges due to high employee turnover and labor shortages, impacting operational efficiency. ## Related Topics [[Claims Management]]; [[Claims Denials]]; [[Claims Processing]]; [[Claim Denials]]