What Is Automated Claims Processing? A Comprehensive Guide

Insurance claims processing tasks (which include tasks like data entry, documentation, and claim completion) can consume an already-packed workload when performed manually. While these tasks are essential to collecting revenue, they’re repetitive and rife with inefficiencies that can detract focus from other, more crucial tasks.

That’s where automated claims processing comes in. Automation plays a crucial role in streamlining the to-dos in claims processing. With AI and machine learning in the mix, teams no longer need to worry about the tedious, time consuming processes involved with processing claims.

The Benefits of Automated Claims Processing

• By automating claims processing, speed and efficiency drastically skyrocket. Tools, such as intelligent document processing bots, eliminate time-consuming manual tasks like data entry and document processing.

• Teams benefit from gaining time to hone in on offering more impactful customer experiences through enhanced communications, leading to expedited claims documentation and client onboarding.

• RPA and AI tools that automate insurance claims processing offer vastly improved data accuracy and human error reduction.  

Manual Claims Processing Challenges

Poor data quality causes U.S. businesses to lose trillions of dollars annually. This bad data derails claims processing, and detailed, manual tasks are often the culprit of inaccurate data.

Not only are manual processes error-prone, but they also create data silos. Scattered data can slow down workflows and decision making and also create inconsistencies across the team and organization.

Additional challenges include:

• Limited visibility into claims status – Without automated tracking, teams struggle to monitor claim progress, leading to inefficiencies and delayed interventions.
• Customer dissatisfaction and churn – Lengthy processing times can frustrate patients and providers, eroding trust and increasing the likelihood of switching to competitors.
• High labor costs and resource strain – Manual claims processing demands significant staffing and extended hours, diverting resources from higher-value tasks.
• Inconsistent prioritization of claims – Without intelligent automation, urgent or high-value claims may not receive timely attention, impacting revenue flow.
• Scalability challenges – Manual processes lack flexibility, making it difficult to handle volume surges efficiently, especially during seasonal spikes or growth periods.
• Delayed insights for decision-making – Manual methods slow down data collection, making it harder to extract real-time insights for performance optimization and compliance tracking.
• Increased training burden – Reliance on manual processing requires extensive staff training, increasing onboarding times and operational risk when experienced employees leave.
• Prone to human fatigue and burnout – Repetitive, error-prone tasks contribute to employee burnout, potentially leading to higher turnover and decreased accuracy.

Automating Different Stages of Claims Processing

Here’s how automation can play a role across the various stages of claims processing. 

Claim Intake: The claim intake process involves receiving, processing, and recording the claim. Insurance teams receive claims (often from brokers) with images and documents with injury data, repair estimates, adjuster notes, etc. Automated tools could streamline data extraction from these multiple sources faster, more accurately, and even improve over time.

Claim Investigation: The information collected during the intake stage should transition seamlessly into your claim investigation as you prepare to ask follow-up questions and seek additional information. Many AI-based automation tools read all documents, gather the appropriate data, and turn it into a structured format so teams don't have to do this work manually.

Claim Evaluation: A claim evaluation states how the insurance company will pay the claim and the amount paid. Proper provisions are crucial in valuing a claim to ensure no underpayments occur. AI-powered automation tools can detect patterns, flag potentially fraudulent claims, and offer increased accuracy to avoid underpayments.

Claim Settlement: Claim settlement is based on factors such as replacement costs, actual cash value, guaranteed replacement cost, and agreed value. Not only can automation tools help you navigate these many calculations more efficiently, but they can also ensure the settlement is paid on time.

Implementing Automation into Claims Processing At Your Organization

When considering implementing automation into your organization’s claims processing, follow these steps to ensure a seamless tech search and onboarding process:

1. Assess your current processes to see what needs improvement and which strengths you can harness. This will help you implement automation that solves your company’s specific claims processing problems, and avoid automating for the sake of automating.
2. Define your company’s objectives to streamline your search for the correct tool. Start by outlining what you need (e.g., robust data analytics, machine learning, or robotic processing) and then you can start to make a list of the tools that offer those capabilities.
3. Evaluate vendors based on the criteria that best suits your company’s needs, such as ease of use, scalability, integration capabilities, customization options, data security, and vendor reputation.
4. A pilot project will slowly introduce new technology so you can assess whether it will work for your company before committing to it 100%.
5. Train your staff to maximize the value of your new claims process automation investment. If they can’t use the tools, they’re of no value.
6. Monitor results from your claims process automation technology over time, such as KPIs for customer satisfaction, revenue, error reduction, etc. This way, you’ll garner the complete picture of its effectiveness (or lack thereof), and can properly evaluate renewals in the future.

The Benefits of Automated Claims Processing

Automating claims processing transforms revenue cycle operations by increasing efficiency and reducing administrative burdens. Key benefits include:

• Faster processing and approvals – Automation accelerates claims submission and adjudication, reducing turnaround times.
• Improved accuracy – AI-driven validation minimizes human errors, leading to fewer denials and rework.
• Lower operational costs – By reducing manual intervention, automation cuts labor costs and optimizes resource allocation.
• Enhanced provider and patient experience – Faster resolutions improve satisfaction and trust among stakeholders.‍
• Greater scalability – Automation enables healthcare organizations to efficiently manage increasing claim volumes without added strain.

Common Misconceptions About Claims Automation

Despite its advantages, some misconceptions persist about automated claims processing:

• "Automation eliminates the need for human oversight." While automation streamlines processes, human expertise is still essential for complex claims and exception handling.
• "The upfront investment outweighs the ROI." Many organizations see rapid returns through cost savings, faster reimbursements, and reduced denials.
• "Automation tools are too rigid or limited." Modern solutions are highly adaptable, integrating with existing systems and evolving to meet changing payer requirements.

Real-World Examples of Automated Claims Processing

Healthcare organizations that implement automation see tangible improvements in claims management. For example:

• By taking action on Adonis alerts, this team improved NCR performance by 10% and improved speed to cash by 14 days.

Summary

Manually processing claims can be time consuming and tedious. Automating these processes can help your organization stay ahead, cut costs, and increase efficiency. This gives your team the bandwidth to focus on higher priority tasks, increasing productivity without increasing anyone’s workload.