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medical claims

Medical healthcare providers face many stiff challenges with the ever-changing and volatile economy. In addition to the rigid business environment, they are constantly challenged by changing rules and regulations, spiraling costs, and mounting customer expectations.

Overall the actual challenge lies in streamlining the processes and keeping them afloat and efficient at all given instances. One process that pre-requisites a higher level of consistency is medical claims processing.

The risk managers are facing trouble keeping the processes straight, simple, and error-proof.

Challenges of Medical Claims Processing

One of the biggest challenges faced by risk managers is to navigate risks and losses with a greater degree of precision. This, however, always becomes an arduous task as the claims data can’t be found in a single place. Usually, this data is dispersed across diverse systems and spaces. As a result, getting this data safely and seamlessly is a lot easier said than done.

While automation does help to make the processes seamless, most medical service providers remain undecided on adopting automation. Most medical providers still prefer to bank on the RMIS (risk management information systems) for managing their claims.

Being a tool, the RMIS can be used to manage risks effectively, and it comes feature rich that can help providers with an array of claims management benefits. These benefits include streamlining workflow processes, organizing data in a single platform, and performing data analysis to enable informed decision-making processes. All of these play a vital role in improving claims outcomes.

6 Ways to Improve the Claims Process

Below are some practices and ways to improve the claims process for controlling denials, and these include:

1. Data update tools and services

The RMIS systems are the most common tool for collecting and consolidating data.

The system offers medical providers the tools required for importing data from third-party carriers. With RMIS, providers can collect all information about claims and claim-related issues. The best part is that this information can be fetched as per your requirements daily, quarterly, or monthly.

A cloud-based RMIS system comes with multiple on-screen tools to facilitate data importing faster, safer, and more accessible with proper encryption.

2. Third-Party system integrations

When you move to integrate third-party systems with RMIS, this activity comes with its own set of benefits.

Doing so streamlines medical claims processing by eradicating the data silos, reducing burdens on your in-house resources like data entry into multiple systems, and weeding out the probabilities of mistakes from processes. This integration also has to be seamless so the data exchange between accounting, HR, and other related departments is seamless. Also, a smooth integration ensures that the applications’ power is used to one’s advantage.

3. Documentation management

Integration of a document management system can put a definitive end to wayward document keeping and maintenance. This is a massive step for streamlining claims processing. For example, it ends the need to spot pf critical documents right at the moment.

DMS (data management systems) enable the providers to go paperless. This also helps to locate and store critical data files swiftly. In addition, most advanced and fast-paced DMS come with feature-rich options that make effective document management simple and easy.

For example, with DMS, one can attach scanned versions of paper documents to an existing record inside the system. This eliminates the chances of delay that stems from missed files. Moreover, the DMS also helps you send email file attachments directly to the claim records, search for files with specific phrases or keywords, and review recent documents by browsing through recently opened files.

4. Automated workflows

The medical claims processing staff continually needs more time. They also have to perform repetitive and slow tasks that not only slow the process but also make it open to errors.

Thus, automating workflows can become highly beneficial to them. For example, triggering auto alerts for issues such as changes made to the claim details or going past the accepted threshold can be extra helpful in processes.

Professionals can also have a closer look and take corrective measures. Automation works to standardize procedures, amplifying efficiency and reducing claims denials and delays.


5. Analytics and benchmarking

Being able to analyze claims made and received over a period of time is essential for smoother operations. What this does is help explore a range of anomalies that require correction for easing processes. There are plenty of software options that cater to this need specifically. Such software pulls out similar claims from a system over a specific period, compares those, and then display the results on a chart to help you understand the deviation in the trends or processes.

Automated retrieval of figures with an apple-to-apple-like comparison makes it easy to comprehend the issues as they can flare up, becoming unmanageable. 

Other than that, the pro claims processing software also helps benchmark claims against a set of parameters derived from lessons learned from the other types of lost-time cases. As a result, these tools can assign a specific score to the claims, and the higher-risk issues can be spotted earlier and dealt with urgency.

6. Dashboards and reports

Medical claims processing becomes easier when you have a clear picture. These pictures can be orchestrated via the dashboard reports. There is plenty of claims processing software that can be put to use for creating custom dashboard reports.

Many of these software comes loaded with hundreds of standardized dashboard templates that can be further tweaked to meet specific needs. Many such software also comes with an auto-schedule feature to effectively distribute reports to all stakeholders. Stakeholders, on their part, review these reports from time to time to fetch strategic insights and make informed decisions.


Embracing integrated systems is a proven way to streamline healthcare claims management. However, such software and tools must come loaded with features such as workflow automation, intuitive reporting, and data analysis – enabling you to accomplish all critical operations with the click of the mouse.

As a medical practitioner, you must also opt for a cloud-based, scalable solution with many integration options. Third-party partners like Physicians Revenue Group, Inc. have years of experience under their belts and present the right technological mix to help you manage your claims processing and denials with great diligence.

PRG, over the years, has set high standards in the handling of claims management that outsourcing your claims management processing has become the best option for your practice.