Experian Health 
Key takeaways:
- Claim denials remain a priority for providers: Experian Health’s 2025 State of Claims survey found that 82% of respondents said reducing denials is an organizational priority and 68% said submitting clean claims is more challenging than a year ago.
- Claim acceptance depends on the entire reimbursement journey, from eligibility and prior authorization through data capture, claim submission, denial management and claim follow-up.
- Automation, analytics and artificial intelligence (AI) can help providers identify risks earlier, route work more effectively and reduce repetitive manual tasks.
Healthcare providers have a dual imperative: deliver high-quality care and capture the revenue needed to sustain it. Yet the claims management process remains burdensome and complex. Denials are common, and changing payer requirements, inefficient workflows and manual tasks can make them worse. The result can be slower reimbursement, pressure on cash flow and more staff time spent on rework.
Improving claim acceptance requires a practical strategy that strengthens data quality, reduces preventable errors and uses technology to support staff before and after claim submission. This article examines common challenges in healthcare claims processing and strategies providers can use to build a more effective claims management process.
Challenges of healthcare claims processing
Claims management remains labor-intensive for many providers. Experian Health’s 2025 State of Claims survey found that 82% of surveyed revenue cycle leaders say reducing denials is a priority for their organization, while 68% say submitting clean claims is more challenging than it was a year ago. The same survey reports that 90% of claim denials are reworked with at least some human review before resubmission.
Why does reimbursement remain so difficult? The answer usually spans the entire reimbursement journey rather than one isolated step.
The healthcare reimbursement journey
The typical claims management process begins well before a claim is submitted.
| Step 1: Prior authorization |
| Many reimbursement challenges begin before care is delivered, during eligibility, benefits verification and prior authorization. Prior authorization is intended to confirm payer approval for certain services, medications or procedures before they are provided. In practice, it can add administrative work for providers and delays for patients. In a 2025 survey, the American Medical Association (AMA) reported that 95% of physicians said prior authorization delays access to necessary care. AMA also reported that physicians complete an average of 40 prior authorizations per week, requiring an average of 13 hours of physician and staff time each week. Incomplete, missing or delayed information can increase administrative burden and create downstream reimbursement risk. |
| Step 2: Data capture |
| The next stage begins after the patient encounter. Intake and billing teams must gather information from multiple sources for coding and claim submission, including electronic health records (EHRs), physician notes, diagnosis codes, payer rules, paper documents and patient-supplied information. When data is incomplete, inconsistent or out of date, errors and denials are more likely. Data quality remains a major pressure point. Experian Health’s 2025 State of Claims survey says 50% of respondents cite missing or inaccurate claim data at intake as a driver of denials. When front-end data is not accurate, a claim can reach the payer with the wrong coverage, authorization or coding information. |
| Step 3: Processing claims denials |
| After submission, the work continues when claims are denied. Denial management is time-consuming because staff must identify the issue, correct the claim, gather missing information and resubmit or appeal when appropriate. Experian Health’s 2025 State of Claims survey found that 41% of respondents report denial rates of 10% or higher, and that 90% of claim denials are reworked with at least some human review before resubmission. That level of manual involvement makes it harder for teams to keep up when denial volume rises. |
Together, these challenges point to the need for a more connected claims management strategy. Better front-end checks, cleaner data, denial prevention and faster follow-up can improve claim accuracy and help staff focus on the claims that need attention most.
Innovating your claims management strategy
Healthcare organizations can address claims acceptance challenges by adopting strategies that strengthen revenue cycle management. Key areas include:
A cohesive and comprehensive claims management process
New approaches to legacy claims management workflows can help address gaps, inefficiencies and errors. A claims management system such as ClaimSource® can help organizations manage claims, remits and denials in one workflow and prioritize high-impact accounts. The goal is not to add another work queue, but to give teams a more connected view of claim activity and the next action needed.
Better data quality and consolidation
Healthcare claims depend on a large volume of data, which increases the risk of errors. Claims also pass through multiple touchpoints and systems, making it difficult to maintain consistent control and oversight. When front-end information is inaccurate, a claim is more likely to require rework later. Tools like Patient Access Curator
use AI at registration to help organizations validate demographics, eligibility and insurance discovery, helping prevent inaccurate data from entering the system.
Organizations can establish clear data-intake standards, reduce incomplete or inaccurate patient information, limit duplicates and use technology to aggregate the information needed for claims processing. These steps can help staff identify gaps before a claim reaches the payer.
Best practices for denial workflows
Back-end denial management presents its own challenges. It consumes staff time and can delay reimbursement. Denial workflow technology can streamline follow-up by organizing work lists, categorizing denials and bringing remittance details, claim status and analytics into the same workflow.
Experian Health’s Denial Workflow Manager can be used as a standalone product or integrated with ClaimSource to align claims and denials information on the same screens. This solution identifies denials, holds, suspensions, zero pays and appeals won or lost with payers through a combination of Electronic Remittance Advice (ERA) and enhanced claim status transactions.
Automation and AI in claims technology
Providers can strengthen claims management with technology that reduces repetitive manual tasks and gives staff earlier insight into denial risk.
Experian Health’s AI Advantage includes two AI-based offerings that work at different points in the claims process. Predictive Denials uses client claims data to identify claims with a high likelihood of denial before submission, so teams can review them. Denial Triage identifies and segments denials by potential value so teams can focus on remits that may have the most impact.
Prior authorization software
Prior authorization is one of the earliest opportunities to reduce downstream claim risk. Technology can help teams determine whether authorization is required, guide users through payer-specific workflows and monitor status.
Experian Health’s Authorizations is an integrated online service that facilitates prior authorization inquiries and submissions. It uses a Knowledgebase that stores and dynamically updates national payer prior authorization requirements, while also allowing clients to add local or community rules. This can help staff work from more current authorization information and reduce manual searching.
Implementing effective claims management strategies
Practical technology can help improve the claims management process when integrated into a broader revenue cycle strategy. Healthcare organizations can use automation and AI to improve front-end data quality, monitor authorization requirements, flag avoidable denial risk and prioritize denial work.
Experian Health offers a portfolio of provider claims management tools designed to help organizations improve claims workflows and work toward faster, more accurate reimbursement.
FAQs
The claims management process is the series of steps a healthcare organization uses to prepare, submit, monitor and resolve payer claims. It typically includes eligibility and authorization checks, data capture, coding, claim submission, denial management, resubmission, appeals and follow-up.
Providers can improve claim acceptance by strengthening front-end data collection, verifying eligibility and authorization requirements early, using claim edits and scrubbing tools, monitoring payer responses and prioritizing denial work by urgency and value.
Automation can support repetitive or rules-based work such as eligibility checks, prior authorization inquiries, claim status monitoring, claim edits and denial routing. It is most effective when paired with governance, staff review and clear escalation paths.
Prior authorization affects claims management because missing, inaccurate or delayed authorization information can create downstream claim risk. A structured workflow can help staff confirm requirements earlier, track status and reduce preventable rework.
Learn more about Experian Health’s claims management solutions or contact us to see how Experian Health can help support your claims management process.
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