Best Healthcare Claims Management Software
Healthcare claims management software is used to streamline the medical claims process, which eases the relationship between provider and insurance company and efficiently speeds up the patient’s payment lifecycle. These solutions leverage automation features so hospitals and clinics can resolve or prevent any hurdles that can potentially disrupt the claims processing and billing workflow. Healthcare claims management software are sold either as standalone products or bundled within medical billing software, revenue cycle management software, or comprehensive medical practice management software. Users of healthcare claims management software include payers, health care providers, and insurance providers.
To qualify for inclusion in the Healthcare Claims Management category, a product must:
Best Healthcare Claims Management Software At A Glance
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- Overview
- User Satisfaction
- Seller Details
Service Center by Office Ally is a trusted Revenue Cycle Management and patient payments platform used by more than 80,000 healthcare providers and health services organizations, which process more th
- Health, Wellness and Fitness
- Medical Practice
- 91% Small-Business
- 6% Mid-Market
657 Twitter followers
- Overview
- User Satisfaction
- Seller Details
Claims Management Pro is a comprehensive SaaS-based claims management solution that far outpaces the average clearinghouse. This application puts you in control of front-end claims cycle activities, w
- Hospital & Health Care
- 47% Small-Business
- 42% Mid-Market
1,540 Twitter followers
- Overview
- User Satisfaction
- Seller Details
Facets is a modular system integrating consumer, care, claims and revenue management to help organizations meet their business goals.
- Insurance
- 47% Mid-Market
- 29% Enterprise
719,403 Twitter followers
- Overview
- Pros and Cons
- User Satisfaction
- Seller Details
Looking to harness the full power of the Tebra platform? Our practice success platform includes a certified electronic health record solution built to empower today’s providers with robust clinical ch
- Owner
- Office Manager
- Medical Practice
- Hospital & Health Care
- 89% Small-Business
- 10% Mid-Market
11,089 Twitter followers
- Overview
- Pros and Cons
- User Satisfaction
- Seller Details
AdvancedMD is a unified suite of software solutions designed for mental health, physical therapy and medical healthcare organizations and independent physician practices. Features include practice man
- Medical Practice
- Hospital & Health Care
- 63% Small-Business
- 27% Mid-Market
46,564 Twitter followers
- Overview
- Pros and Cons
- User Satisfaction
- Seller Details
What is SAS Fraud, Anti-Money Laundering & Security Intelligence? Software solutions in the SAS Fraud, Anti-Money Laundering and Security Intelligence suite deliver fast, on-target insights throug
- Banking
- Financial Services
- 50% Enterprise
- 28% Mid-Market
61,921 Twitter followers
- Overview
- Pros and Cons
- User Satisfaction
- Seller Details
athenahealth is providing cloud-based services for electronic health records (EHR), revenue cycle management & medical billing, patient engagement, care coordination, and population health managem
- Hospital & Health Care
- Medical Practice
- 44% Small-Business
- 35% Mid-Market
24,583 Twitter followers
- Overview
- Pros and Cons
- User Satisfaction
- Seller Details
Delivering on the promise of health information technology, Henry Schein Medical Systems/MicroMD provides simple yet powerful EMR and practice management solutions that facilitate the delivery of supe
- Hospital & Health Care
- 60% Small-Business
- 28% Mid-Market
150 Twitter followers
- Overview
- User Satisfaction
- Seller Details
TriZetto offers consulting, IT, and business process solutions to streamline the deployment and adoption of technologies and improve operations for payers and providers in the health care industry. Tr
- 46% Enterprise
- 38% Mid-Market
719,403 Twitter followers
- Overview
- User Satisfaction
- Seller Details
From the first phone call with a new patient through final claim reconciliation and payment, you need a simpler way to collect, submit, and track the administrative, clinical, and financial data that
- Medical Practice
- Hospital & Health Care
- 63% Small-Business
- 23% Mid-Market
2,106 Twitter followers
- Overview
- User Satisfaction
- Seller Details
Waystar provides market-leading technology that simplifies and unifies the revenue cycle. Their cloud-based platform streamlines workflows and improves financials for healthcare providers of all kinds
- Billing Manager
- Office Manager
- Hospital & Health Care
- Medical Practice
- 61% Small-Business
- 32% Mid-Market
2,025 Twitter followers
- Overview
- User Satisfaction
- Seller Details
Beacon is a leading-edge software firm specializing in health claims management solutions for healthcare payers. SpyGlass, our innovative, cloud-based claims processing software, paired with HIPAA Dir
- 45% Mid-Market
- 27% Enterprise
40 Twitter followers
- Overview
- Pros and Cons
- User Satisfaction
- Seller Details
Integrated, customizable, ONC-certified clinical management and practice management software for healthcare providers and care organizations. Founded in 1999 and headquartered in Maryland, RXNT's s
- Hospital & Health Care
- Medical Practice
- 62% Small-Business
- 32% Mid-Market
- Overview
- User Satisfaction
- Seller Details
eClaimStatus is a Health insurance eligibility verification software that is easy to Use, comes with zero setup or maintenance hassles ,assures real-time , eligibility verification from 700+ payers, f
- 78% Small-Business
- 22% Mid-Market
6 Twitter followers
- Overview
- User Satisfaction
- Seller Details
Veradigm Payerpath® is an Internet-based suite of solutions that addresses every step in the reimbursement cycle.
- 50% Small-Business
- 25% Enterprise
441 Twitter followers
- Overview
- Pros and Cons
- User Satisfaction
- Seller Details
Zelis is modernizing the business of healthcare by building something remarkable: a connected platform that bridges gaps in the financial system and aligns interests across healthcare insurers, provid
- Hospital & Health Care
- 44% Mid-Market
- 38% Small-Business
441 Twitter followers
- Overview
- User Satisfaction
- Seller Details
Oracle Health Insurance Claims Management supports the import, processing, and release of claims for payment. Authorizations can be recorded for the procedures that require permission in advance. Clai
- 63% Enterprise
- 25% Mid-Market
822,135 Twitter followers
- Overview
- Pros and Cons
- User Satisfaction
- Seller Details
Practice Management solution lets you manage patient records, insurance eligibility, documents, and billing in one place to maximize staff efficiency.
- 64% Small-Business
- 27% Mid-Market
221 Twitter followers
- Overview
- Pros and Cons
- User Satisfaction
- Seller Details
Clearwave is the Patient Revenue Platform for High-Growth Practices. Clearwave provides a purpose-built platform turbo-charged to enable practices to grow revenue, increase point-of-service collection
- Hospital & Health Care
- 93% Mid-Market
- 7% Small-Business
237 Twitter followers
- Overview
- User Satisfaction
- Seller Details
ABILITY EASE All-Payer was engineered by leveraging over a decade of experience troubleshooting EDI submission pain points to create a system that reduces first-pass rejections.
- 33% Enterprise
- 33% Mid-Market
1,540 Twitter followers
- Overview
- Pros and Cons
- User Satisfaction
- Seller Details
CareCloud Inc. brings disciplined innovation to the business of healthcare. Our suite of technology-enabled solutions helps clients increase financial and operational performance, streamline clinical
- Hospital & Health Care
- Medical Practice
- 67% Small-Business
- 20% Enterprise
6,482 Twitter followers
- Overview
- Pros and Cons
- User Satisfaction
- Seller Details
Remedly is all of the software your practice needs in one cloud-based solution. Tackle scheduling, invoicing, electronic medical records, billing, marketing, inventory management, and more -- all in o
- 56% Small-Business
- 39% Mid-Market
- Overview
- Pros and Cons
- User Satisfaction
- Seller Details
ClaimVantage offers industry-leading software for managing life, health, and absence claims efficiently and securely, helping you deliver superior customer service for a competitive edge. Hosted on t
- 75% Mid-Market
- 25% Small-Business
- Overview
- Pros and Cons
- User Satisfaction
- Seller Details
HST Pathways is the leading provider of a suite of products that have been thoughtfully and clinically designed for the surgery center industry. Our many software offerings provide ASCs with intuitive
- Hospital & Health Care
- 71% Small-Business
- 29% Mid-Market
- Overview
- User Satisfaction
- Seller Details
Founded in 1996 and headquartered in Oregon, PLEXIS serves healthcare payer administrative organizations serving over 50 million people in all 50 states and 15 countries. PLEXIS provides enterprise co
- 75% Small-Business
- 25% Mid-Market
178 Twitter followers
- Overview
- User Satisfaction
- Seller Details
QuickCap is an advanced healthcare claim processing system built for IPAs, PHOs, MSOs and other management organizations. It is designed to process EDI and manual claims, capitation, eligibility, refe
- 100% Small-Business
375 Twitter followers
- Overview
- User Satisfaction
- Seller Details
We help you make right easy by preventing denials, protecting revenue, and eliminating manual claim edits with automation that catches errors before claims go out. Our smart, customizable rules ensure
- 50% Enterprise
- 50% Mid-Market
5,561 Twitter followers
- Overview
- User Satisfaction
- Seller Details
iSalus Healthcare, an EverCommerce company, is a true all-in-one-solution that enables clinicians to manage, monitor and improve their patients’ health from start to finish and beyond. iSalus offers e
- 67% Mid-Market
- 33% Small-Business
2,477 Twitter followers
- Overview
- User Satisfaction
- Seller Details
SSI Claims Director is an industry-leading claims management solution proven to streamline processes and decrease denials through unmatched edits and a near-perfect clean claim rate. It guides users s
- 67% Small-Business
- 33% Mid-Market
663 Twitter followers
- Overview
- User Satisfaction
- Seller Details
Total environment designed to manage the needs of workers' compensation claims.
- 75% Small-Business
- 25% Mid-Market
718 Twitter followers
- Overview
- User Satisfaction
- Seller Details
ABILITY | PC-ACE is a complete electronic claims submission and management software application. It can be used in a standalone configuration or in conjunction with your existing claims management sys
- 50% Enterprise
- 50% Small-Business
1,540 Twitter followers
- Overview
- User Satisfaction
- Seller Details
Claims processing and payment software with unlimited plans, on-line repricing and PPO fee schedules capabilities.
- 50% Mid-Market
- 25% Enterprise
12 Twitter followers
- Overview
- User Satisfaction
- Seller Details
The HSP Payer Suite provides a single-source database, core administrative system, web portals, and open system with web services to quickly automate current and future healthcare regulations and busi
- 50% Enterprise
- 50% Mid-Market
14,649 Twitter followers
- Overview
- User Satisfaction
- Seller Details
Payment Infrastructure for Healthcare. Eligible is a software suite that increases yield while decreasing cost to collect.
- 50% Enterprise
- 50% Small-Business
- Overview
- User Satisfaction
- Seller Details
File-Mate 1500 intuitive, user-friendly interface lets you get started with a minimal learning curve. It breaks the HCFA / CMS 1500 form into logical sections and guides you through each screen, makin
- 100% Small-Business
6 Twitter followers
- Overview
- User Satisfaction
- Seller Details
For nearly 40 years RAM Technologies has been providing enterprise software solutions for health plans administering government sponsored healthcare with a specific focus on Medicare Advantage (MA) an
- 50% Small-Business
- 50% Enterprise
- Overview
- User Satisfaction
- Seller Details
The industry’s first intelligent, multi-specialty medical billing software. Streamlining billing and patient collections for over 46,000 physicians across the country.
- 100% Mid-Market
- Overview
- Pros and Cons
- User Satisfaction
- Seller Details
Cloud based platform for electronic medical records. Features include clinical orders tracking and hospital outreach solutions.
- 50% Mid-Market
- 50% Small-Business
110 Twitter followers
- Overview
- User Satisfaction
- Seller Details
OmegaBill Dental allows you to process dental insurance claims and provide billing services for dental practices by allowing you to receive claims electronically from dental offices in different forma
- 100% Small-Business
- Overview
- User Satisfaction
- Seller Details
Origami Risk is a highly configurable, integrated SaaS platform for insurance, risk, safety, and compliance management. Origami Risk provides organizations with a centralized system to automate critic
- 70% Enterprise
- 20% Small-Business
1,055 Twitter followers
- Overview
- User Satisfaction
- Seller Details
SmartData Solutions has many solutions in healthcare area, document management and more.
- 50% Enterprise
- 50% Small-Business
106 Twitter followers
- Overview
- User Satisfaction
- Seller Details
Wisedocs is an intelligent document processing AI for the medical sector. We allow medical records and other data to be processed in real time, with advanced customizable machine learning outputs. Fou
- 50% Small-Business
- 50% Enterprise
- Overview
- User Satisfaction
- Seller Details
DataCare provides software solutions for the workers' compensation industry to better manage medical treatment and billing. Their Medical Process Manager and UR platforms help integrate a medical aspe
- 60% Mid-Market
- 20% Small-Business
210 Twitter followers
- Overview
- User Satisfaction
- Seller Details
Web-based medical billing, practice management and EMR software that uses artificial intelligence.
- 80% Small-Business
- 40% Enterprise
1,299 Twitter followers
- Overview
- User Satisfaction
- Seller Details
An analytics-driven claims and remittance management solution for healthcare providers who want to automate workflows, improve resource utilization, and accelerate cash flow.
- 100% Enterprise
36,426 Twitter followers
- Overview
- User Satisfaction
- Seller Details
Chiropractic EHR hosted in the cloud, patient engagement portal, easy to customize, speech recognition, excellent and timely support.
- 100% Mid-Market
6 Twitter followers
- Overview
- User Satisfaction
- Seller Details
Dental Hero helps lighten the load so you can focus on being a dental hero.
- 100% Small-Business
- Overview
- Pros and Cons
- User Satisfaction
- Seller Details
For 15 years, Enable Healthcare has been a prominent player in the EHR market. Our state-of-the-art AI-powered EMR software, is reshaping how healthcare professionals handle patient records. Packed wi
- 100% Small-Business
- Overview
- User Satisfaction
- Seller Details
Family Health Care Manager lets you see exactly which visits you need to submit and which you’re waiting for your insurer to process. Track your deductibles and see if you’ve reached your out of pocke
- 100% Enterprise
- Overview
- User Satisfaction
- Seller Details
FINEOS Claims is a best in class, customer-centric, web-based claims processing software solution.
- 100% Mid-Market
1,072 Twitter followers
- Overview
- User Satisfaction
- Seller Details
Futura Practice Management is a Web-based practice management solution for small and midsized health care practices. The software features schedule management, which allows physicians to manage patien
- 100% Mid-Market
- Overview
- User Satisfaction
- Seller Details
All-in-one electronic medical records (EMR), appointment scheduling, and medical billing software package for Vista and XP.
- 100% Enterprise
540 Twitter followers
- Overview
- User Satisfaction
- Seller Details
OCExaminer delivers charge capture software designed to help organizations optimize its revenues.
- 100% Small-Business
9 Twitter followers
- Overview
- User Satisfaction
- Seller Details
Parascript automates the extraction of meaningful, contextual data from image and document-based information to support transactions, information governance, fraud prevention, and business processes.
- 100% Small-Business
505 Twitter followers
- Overview
- User Satisfaction
- Seller Details
Medical practice management and billing solution with optional automated bad debts / collection agency tracking functionality.
- 100% Small-Business
16 Twitter followers
- Overview
- User Satisfaction
- Seller Details
With deep industry expertise and technology delivered through person-to-person contact, only Quadax gives revenue cycle professionals the freedom to consistently add value to their organization. Our c
- 50% Enterprise
- 50% Small-Business
141 Twitter followers
- Overview
- User Satisfaction
- Seller Details
Quick Practice is a medical practice management software that includes electronic billing service, calendar, patient database, and more.
- 100% Mid-Market
11 Twitter followers
- Overview
- User Satisfaction
- Seller Details
Easy835 provides data management service statuses electronic clams for a fraction of the cost and time of billing and collections staff, which equates to more cash for our clients.
- 100% Small-Business
816 Twitter followers
- Overview
- Pros and Cons
- User Satisfaction
- Seller Details
Stedi is the only API-first healthcare clearinghouse. Health tech companies use Stedi to automate healthcare transactions like eligibility checks and claims using APIs that support thousands of payers
- Logistics and Supply Chain
- 79% Small-Business
- 21% Mid-Market
1,657 Twitter followers
- Overview
- Pros and Cons
- User Satisfaction
- Seller Details
TruBridge is a service provider focused on providing business office, consulting and managed IT services to community healthcare organizations.
- 200% Mid-Market
- 100% Small-Business
374 Twitter followers
- Overview
- User Satisfaction
- Seller Details
AcceliCLAIM manages every step of the Medicaid claiming process, from performing Medicaid eligibility checks, to building and submitting claims, to processing remittance files. The system performs com
1,959 Twitter followers
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- User Satisfaction
- Seller Details
AccuReg offers a full suite of all critical front-end RCM process solutions that hospital Patient Access departments need.
402 Twitter followers
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- User Satisfaction
- Seller Details
- Overview
- User Satisfaction
- Seller Details
AltuMed PracticeFit – Intuitive Medical Billing Software Modern, cloud based, easy to use software with tons of features at very affordable cost. AltuMed PracticeFit is an Electronic Practice Manage
- 100% Small-Business
- Overview
- User Satisfaction
- Seller Details
Anagram is a Software as a Service that helps eye care providers with all aspects of vision insurance billing and lab management -- pricing, ordering, rebating, and more.
- 100% Small-Business
167 Twitter followers
- Overview
- User Satisfaction
- Seller Details
Offers OneTouch® electronic claims processing, real-time eligibility verification, patient statements delivery, and electronic remittance advice (ERA) and tools that accelerate the patient payment col
101 Twitter followers
- Overview
- User Satisfaction
- Seller Details
ApexonHealth is the healthcare division of Technosoft Corp. The company provides solutions for revenue cycle management, coding, advanced analytics, claims management and other healthcare-focused BPM
373 Twitter followers
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- User Satisfaction
- Seller Details
Denials Intelligence is a denial management solution designed to generate a rich set of reports on all claim and remit activity.
- Overview
- User Satisfaction
- Seller Details
Artsyl Claim Action is designed to capture, verify, and route medical claim data to back-end systems without manual data entry, and is able to capture every field from professional claim forms used by
6,203 Twitter followers
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- User Satisfaction
- Seller Details
- Overview
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Bristol Byte is a cloud-based web application, tactically designed for healthcare entities. It accelerates revenue flow and helps to manage their workflow process in a more efficient manner. Bristol B
- Overview
- User Satisfaction
- Seller Details
CareEco is a healthcare technology ecosystem designed to simplify and streamline the process of providing healthcare to patients. The CareEco platform can either augment or fully replace your pract
- Overview
- User Satisfaction
- Seller Details
A single platform designed to enable cleaner claims, improve communication and speed up reimbursement
- Overview
- User Satisfaction
- Seller Details
Revenue cycle management services for hospitals and health systems that want to increase cash flow and achieve sustainable financial performance.
36,426 Twitter followers
- Overview
- User Satisfaction
- Seller Details
A clinically-based claims payment solution for payers that want to create and deploy flexible, automated rules to help improve payment accuracy, reduce appeals, and realize medical and administrative
36,426 Twitter followers
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- User Satisfaction
- Seller Details
ChartLogic Billing Service Solutions provides the tools you need to increase efficiency and get your practices paid sooner.
- 100% Small-Business
95 Twitter followers
- Overview
- User Satisfaction
- Seller Details
The Cirius Group has transformed healthcare revenue cycle business operations for over 35 years. Cirius delivers industry leading KPI's by streamlining business office functions with highly customize
- Overview
- User Satisfaction
- Seller Details
Analyze proposed bills to get visibility into problems and actionable insight before the problems leave the business office.
- Overview
- User Satisfaction
- Seller Details
Comindware Health Insurance Claims Management software provides for effective claims processing and enables elimination of inconvenient and error-prone paper and email-based operations taking all comm
- 100% Mid-Market
277 Twitter followers
- Overview
- User Satisfaction
- Seller Details
Crosby Health is a healthcare technology company specializing in automating the clinical appeals process for hospitals, health systems, specialty practices, and revenue cycle management providers. By
- Overview
- User Satisfaction
- Seller Details
DrsMagic is a comprehensive software package for medical clinics.
- Overview
- User Satisfaction
- Seller Details
EbixEnterprise is uniquely structured-in Business Blocks, allowing you to change coverage categories as your book of business changes. And every block is built on the powerful EbixEnterprise Claims LX
1,716 Twitter followers
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- User Satisfaction
- Seller Details
Startech Software's TotalEclipse product is a fully featured single-database Claims Management & Medical Bill Review Software application. Representing the culmination of over three years of devel
718 Twitter followers
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- User Satisfaction
- Seller Details
E-COMB is a web based solution for generating medical claims complying with the HIPAA transaction and code set standards, regulated by the US Government following the recommendations of American Natio
151 Twitter followers
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- User Satisfaction
- Seller Details
Claim Agent is a claims management software designed to have an intuitive functionality that optimizes workflow, reduces errors, and accelerates cash flow.
7 Twitter followers
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- User Satisfaction
- Seller Details
Essentials Pro is Availity’s premier revenue cycle management clearinghouse, enabling some of the nation’s largest and most successful providers, hospitals, and health systems to streamline their work
2,106 Twitter followers
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- User Satisfaction
- Seller Details
E-TPA is a comprehensive, end-to-end, and highly customizable Enterprise Healthcare Insurance Solution. Our engine will streamline, digitize, and reduce the operational cost of your organization’s pro
- Overview
- User Satisfaction
- Seller Details
Upgrade your claims processing by unifying data from all incoming communication channels, performing pre-submission checks to create clean claims, and intelligently routing claims for optimal processi
- Overview
- User Satisfaction
- Seller Details
From coding and billing support to claims management systems, medical lockbox solutions, and integrated data management, Exela offers full claim lifecycle tools that improve patient financial services
- Overview
- User Satisfaction
- Seller Details
EzyMed Online 4 is a fully integrated Medical Practice Management software for General Practices, Radiology and Specialists Centres.EzyMed Online 4 encompasses all functions required for the Medicare
- Overview
- User Satisfaction
- Seller Details
Thrive holistically re-engineers the revenue cycle throughout the patient's journey, from patient access to accurate clinical documentation and coding to proper reimbursement.
- Overview
- User Satisfaction
- Seller Details
- 100% Mid-Market
522 Twitter followers
- Overview
- User Satisfaction
- Seller Details
Fusion EDI is a cloud based B2B platform that allows you and your business partners to exchange data dynamically. It is entirely compliant with the current worldwide standards and laws to assist the f
- Overview
- User Satisfaction
- Seller Details
GoClaim is a comprehensive Medicaid reimbursement management platform specifically designed for educational institutions. Tailored to meet the unique needs of schools, GoClaim simplifies the complex p
- Overview
- User Satisfaction
- Seller Details
EMR that is fully integrated with practice management functionality, and free to offices with one to two providers.
- Overview
- User Satisfaction
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HxOne is the premiere healthcare payer solutions company that offers customized solutions for commercial and governmental health benefit administrators.
236 Twitter followers
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- User Satisfaction
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Manage your members' healthcare and networks with a cloud-based healthcare delivery system. Automate claims processing for managed care organizations.
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- User Satisfaction
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Automate your Medicare billing management with specialized Medicare revenue cycle management software that corrects complex and multi-step claims, flags receivables at risk, and allows you to perform
1,540 Twitter followers
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- User Satisfaction
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- Overview
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Bilingual English/Spanish EHR with SNOMED-CT-based data coding.
Learn More About Healthcare Claims Management Software
Any healthcare organization, whether it’s a small, specialized practice or an enterprise healthcare system, deals with invoices, payments, insurance claims, and overall finances. Efficient management of these financial processes is crucial for maintaining profitability and ensuring smooth operations. This is where healthcare claims management software comes into play.
What is healthcare claims management software?
Healthcare claims management (HCM) software, also called medical claims software, automates a medical practice’s invoicing and claims processes.
From initial submission to adjudication, it handles all steps to ensure claims are processed accurately and quickly, reducing the risk of errors and denials. It’s an essential tool for medical practices, hospitals, and billing companies aiming to boost efficiency in the billing process.
The solution can turn an office paperless and digital, which will optimize the process by reducing overall billing errors, time spent on monitoring and managing the claims, and lead to real-time processing of claims.
Implementing medical claims management software will help hospitals and clinics improve financial performance with automated processes and prevent any hurdles that can potentially disrupt the claims processing and billing workflow.
What are the common features of healthcare claims management software?
The following are some core features within healthcare claims management that can help users manage a more effective and efficient claims process.
- Claims submission and processing: Electronic claims processing feature automates the submission process for insurance claims, enabling faster and more efficient processing.
- Claims scrubbing: HCM identifies and corrects errors or discrepancies in claims before submission. It uses validation rules to ensure accurate coding and billing, reducing the chances of denials.
- Denial management: A good medical claims software tracks and manages denied claims, providing tools to resubmit claims with corrected information. It offers denial analytics to help identify common denial reasons and improve the accuracy of future claim submissions.
- Real-time eligibility verification: This feature checks a patient’s insurance eligibility and coverage in real time before services are rendered. It prevents claim rejections due to patient ineligibility or insufficient coverage.
- Automated coding: This is an essential feature in HCM that incorporates medical coding standards like the International Classification of Diseases - ICD-10, and Current Procedural Terminology (CPT) in claims to ensure proper coding of procedures and diagnoses. It reduces manual coding errors and speeds up claims processing.
- Claims tracking: This feature provides real-time tracking of claim statuses, from initial submission to adjudication. It offers insights into claim progress and outcomes, helping users manage follow-ups efficiently.
- Compliance management: All healthcare claims management software ensures adherence to healthcare regulations such as the Health Insurance Portability and Accountability Act (HIPAA), and ICD-10 coding. It regularly updates to align with new regulatory changes to avoid compliance risks.
- Revenue cycle management (RCM) integration: Best HCM software works seamlessly with broader RCM systems, electronic health records (EHR), and billing systems to streamline the entire billing and payment process. It supports end-to-end RCM workflows, improving financial outcomes for healthcare providers.
- Customizable dashboards: HCMs offer user-friendly visual displays of key metrics such as claim status, denial rates, and overall financial performance.
- Patient payment processing: This software manages patient billing, invoicing, and payment processing for self-pay patients or out-of-pocket costs. It offers payment plans, online payment options, and reminders to improve patient collections.
What are the benefits of healthcare claims management software?
Best healthcare claims management software does more than automate billing and invoicing, thereby reducing loads of paperwork and time usually spent on creating statements, verifying insurance coverage, and processing claims. A few other benefits of using healthcare claims management software include:
- Digital claims: Automation is key to improving efficiency and accuracy in the healthcare industry because the claims process can be very manual. Implementing a digital claims process will reduce the amount of paper-based processes, increase clean claim submissions, reduce errors, and create more thorough, accurate documentation.
- Efficient processing: The various stages of claims processing can be very time consuming due to errors. Healthcare claims management software will allow for optimized processing and collection of claims. It will also increase efficient reimbursement cycles and communications with insurance companies.
- Patient satisfaction: If the claims process is filled with errors and inaccuracies, patients will likely be upset and frustrated with the system. Healthcare claims management software will allow for tracking, monitoring, and reporting of patients’ finances and customization of billing according to specialized practice needs—all of which leads to improved patient engagement and satisfaction.
- Adjudication: To adjudicate claims means to automate how the responsibility of the payer is determined. Auto-adjudication can be implemented in the claims process, which leads to a faster payment process for providers, more accurately processed claims, fewer pending or outstanding claims, and an improved patient experience.
- Compliance adherence: There are many compliance issues, such as Medicare and Medicaid, and numerous state and federal regulations, which makes the claims process complex. The privacy and security requirements of the Health Insurance Portability and Accountability Act (HIPAA) are critical to a successful practice. HIPAA violations can lead to fines and significant damage to a provider’s reputation. Ensuring the healthcare claims processing systems are fully compliant is critical to remain compliant and maintain optimal levels of patient service.
Who uses HCM or medical claims software?
Common users of healthcare claims processing software include:
- Healthcare providers: Hospitals, clinics, private practices, and specialty care centers are the primary users of HCM software. They use it to streamline billing, manage insurance claims, and enhance revenue cycle management.
- Medical billing and coding companies: These companies rely on HCM software to handle claims processing for healthcare providers, managing everything from submission to denial resolution.
- Health insurance companies and payers: These parties use medical claims software to process, verify, and adjudicate claims, ensuring accurate payment and compliance.
- Third-party administrators (TPAs): TPAs utilize this software to provide outsourced claims management services, covering compliance, claims processing, and auditing.
- Healthcare clearinghouses: These companies employ HCM software to validate and process claims between healthcare providers and insurers, ensuring claims meet payer requirements and reducing rejections.
- Patients: Patients indirectly interact with healthcare claims management software through billing and payment processes. The software manages patient billing, tracks out-of-pocket costs, and facilitates payment plans.
Healthcare claims management software pricing
The cost of healthcare claims management software can vary significantly based on factors like the number of users, the complexity of features, the deployment model, and the specific vendor.
- Number of users: The more users accessing the software, the higher the cost.
- Features and functionality: The complexity and breadth of features, such as advanced analytics, automated coding, and real-time reporting, will impact the price.
- Deployment model: Cloud-based solutions are generally more affordable than on-premise solutions due to lower upfront costs and reduced maintenance overhead.
- Additional services: Consider costs for implementation, customization, training, and ongoing support.
Here’s a look at the common pricing models of medical claims software:
- Subscription-based: Many healthcare claims management systems operate on a subscription model, often charged monthly or annually. Pricing can range from a few hundred to several thousand dollars per month, depending on the software's features and the number of users. Subscription-based models typically include customer support, regular updates, and cloud hosting.
- Per-claim pricing: Some software solutions use a pay-per-claim model, where healthcare providers are charged based on the number of claims processed. This model is often preferred by smaller practices that handle fewer claims and want to keep costs predictable.
- One-time license fee: Some on-premise solutions require a one-time licensing fee, making them a significant upfront investment. This model is common for larger organizations wanting full software infrastructure control. However, ongoing costs for maintenance, updates, and support should also be considered when evaluating this pricing model.
- Free or freemium: Some vendors offer free basic versions of their software, with premium features and services available for an additional fee.
Many healthcare claims management software providers offer custom pricing, tailoring their offerings to each client's specific needs. Contact vendors directly to discuss specific needs and obtain customized quotes.
Challenges with healthcare claims management software
Software solutions can come with their own set of challenges.
- Denial management: The biggest challenges to claims denials include coding errors and reimbursement policies. Providers and administrators have to constantly learn new codes and adding this information can still be a manual process. There may need to be communications between the provider, insurer, and patient as not all claims will be approved and processed immediately.
- Training and onboarding: Like any piece of technology, effective training and onboarding will speed up the adoption of the healthcare claims management solution. The quicker practitioners and administrators become comfortable with the software, the more empowered they will feel when utilizing and communicating about the solution. Regular training will also reduce any wrong use, insufficient documentation, or miscommunication. Training will benefit staff when it comes to everyday use, as well as reducing errors in coding.
- Multiple systems: Not all clinics have coexisting patient management and billing systems. These systems may or may not communicate with each other and this can lead to a less efficient claims management process.
How to buy healthcare claims management software
There are unique needs to consider when assessing software to purchase—size and team member count, onboarding process, software cost, vendor customer support options, mobile compatibility, and customization are some of them. Buyers must determine what set of features will help the users be more efficient and meet the needs of the claims management process.
Choose a selection team
To choose a selection team, decision makers need to involve subject matter experts from all teams that will use the system. For any organization, this will likely involve healthcare practitioners, office staff, claims management employees, and decision makers. An IT administrator should also be present to weigh in on technical concerns with the products. The selection team should be a representation of the people who will use the system.
Create a long list
An initial list of potential healthcare claims management solutions should include any products that meet the basic feature requirements. At this stage, focus on identifying options that align with your essential needs, such as claims submission, denial management, compliance, and integration capabilities. This list serves as a broad overview of potential vendors that could fit your organization.
Create a short list
After a long list has been created, it’s time to look at each product in more detail to determine if it sounds like it will meet the needs of the healthcare providers interested in purchasing this software. This involves analyzing additional features beyond the essentials, such as AI-powered automation, analytics, or enhanced compliance tools.
Consider the software’s scalability, user-friendliness, and ability to drive efficiencies and improve compliance. Select the top contenders that seem most aligned with your requirements.
Conduct demos
Demos are a great opportunity for buyers to see how the software works. Only the shortlisted vendors should be invited to demonstrate their solutions. Demos should be performed live, using the system, and not through slide decks and screenshots.
Request a walkthrough from the perspective of all user roles—administrators, claims staff, and healthcare providers—to assess ease of use, navigation, and overall user experience. This will help you understand how the software operates in real-world scenarios.
Negotiation
After narrowing in on the preferred product, it’s time to negotiate a pricing package. Buyers must consider the software's pricing model, such as whether the seller charges a flat monthly fee or, more commonly, a fee based on how many user seats the buyer needs. Buyers should also note if they can negotiate to add more user seats to a package that would otherwise meet their needs. They might also consider negotiating a discount in exchange for signing a multi-year contract.
Final decision
The final decision should involve feedback from all primary users. Ensure the software is user-friendly, easy to implement, and capable of improving operational efficiency. Consider its impact on the patient experience, compliance, and overall claims performance. The selected solution should align with your organization’s long-term goals and provide clear value for your investment.
Healthcare claims management software trends
The healthcare claims management software landscape is constantly evolving, driven by technological advancements and changing industry regulations. Here are key trends shaping the industry:
- Artificial intelligence and automation: AI can transform claims management by automating claims scrubbing, denial prediction, and error detection. By analyzing claims data in real-time, AI tools minimize errors, increase approval rates, and speed up the entire claims process, making operations more efficient.
- Cloud-based solutions: Cloud-based claims management software offers flexibility, scalability, and cost efficiency. It enables providers to access real-time data, supports remote work, simplifies software updates, and ensures compliance, making it a critical choice for organizations aiming for seamless digital transformation.
Researched and written by Dominick Duda
