Healthcare claims processing should be straightforward: a provider delivers care, sends the bill, and gets reimbursed by the payer. Simple, isn’t it?
But the numbers paint a different reality. Experian’s State of Claims 2024 reveals that 38% of respondents believe claims are denied 10% of the time, or more, whereas 11% of them say these are denied over 15% of the time.
Yet, the same study portrays another reality. Nearly 50% of healthcare providers rely on manual claims handling processes, resulting in errors, delays, and room for fraud.
The problem isn’t effort. It’s the system.
Generative AI is enabling 20–25% reductions in loss-adjusting costs, offering a powerful path to operational savings. As $1.3 billion in digital health investments surge forward this year, automation is the need of the hour.
Healthcare claims automation is reshaping a disconnected system. AI-powered process automation platforms like FlowForma are streamlining claims with smart forms, one-click document generation, and easy integration with existing tools. Let’s dig deeper.
Healthcare claims processing automation is the use of technology, primarily AI-powered process automation and machine learning, to streamline tedious claims handling processes like data validation and verification, claims adjudication, workflow optimization, and fraud detection in the healthcare sector.
It minimizes human intervention, improves accuracy, and speeds up the entire claims lifecycle from submission to approval.
Healthcare claims automation enables efficient claim handling, significantly reducing human errors and other factors leading to claim denials.
These systems are powered by AI and machine learning that handle the heavy lifting: extracting data, validating claim codes, and verifying claimants' information accurately.
NLP (natural language processing) even reads doctors’ notes and scanned forms to ensure nothing gets missed.
The outcomes of healthcare claims automation are:
Health insurance claims follow a set process, though details vary by insurer and region. Most providers use clearinghouses to format and submit claims correctly.
Here’s a simplified breakdown of how health insurance claims are processed.
How health insurance claims are processed
Here's where traditional claims processes break down:
Manual claims review and submissions often include incorrect or incomplete claimant information, missing IDs, or duplicate entries. Providers are trying to move fast, but speed, without accuracy, leads to denials and delays.
Verifying policies, reviewing supporting documentation, and checking for inconsistencies require toggling between databases, which is a slow, error-prone process.
The involvement of multiple stakeholders increases the chances of risks and errors due to various reviews and resubmissions. And incorrect verifications increase the risk of fraudulent claims going undetected.
Denials due to filing errors, formatting mismatches, or late submissions are common, and reimbursement can take weeks.
Automation has the power to make healthcare claims management faster, more accurate, and more cost-effective.
A recent study, “Automation in Healthcare Claims Processing: Enhancing Efficiency and Accuracy,” highlights how AI-driven automation is already delivering promising results.
These study results conclude how AI-driven healthcare claims automation cuts through the labyrinth of documentation, approvals, and outdated workflows.
Let's dig a little deeper and explore how healthcare claims automation facilitates faster, smarter and more reliable claims handling.
Automating claims processing workflow can reduce processing costs by up to 30%.
In fact, with automation tools like FlowForma, healthcare providers and insurers can save up to $80,000 per process.
Automation predicts claim outcomes, flags high-risk denials, spots data issues, and estimates processing times. This helps prioritize and push clean claims through faster.
Automation standardizes how data is captured and validated, minimizing human errors and improving claims accuracy.
Automated healthcare claims software reduces processing time by as high as 70% (which may vary across organizations). Members get quicker responses, providers receive faster payments, and internal teams deal with fewer errors and rework. Reduced complaints and smoother workflows improve trust, loyalty, and overall satisfaction.
Fraud, including waste and abuse in healthcare, is a major threat, draining over $100 billion annually from the system. Outdated systems, fragmented claims data, and blurred accountability give fraud practices abundant opportunities to thrive.
This is where automation steps in with the absolute urgency of fraud detection. Healthcare automation tools like FlowForma can instantly flag questionable claims, identify suspicious billing behavior, and prevent duplicate submissions.
Payers save money, maintain trust, protect their members, and ensure medical services reach those who truly need care.
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Here are five leading examples of automation in healthcare:
Accurate clinical safety checks are necessary to prevent claim delays or denials. Claims can be rejected without proper documentation, affecting patient care and hospital finances.
Automating these checks ensures they're done accurately and consistently.
An example comes from Blackpool Teaching Hospitals NHS Foundation Trust, which used FlowForma to digitize its clinical safety checks.
The results were transformative: not only did they significantly improve compliance, but they also cut down on administrative and clinical workload, freeing up staff to focus more on patient care and less on paperwork.
Accommodation and agency spending requests involve a lot of back-and-forth approvals, causing delays and human errors.
With similar issues, Blackpool Teaching Hospitals NHS Foundation Trust's HR team used FlowForma to build a New Starter form and an Agency Spend request with built-in approvals that escalated to senior management.
The result? Faster, more accurate approvals eased staff workload and sped up claims processing.
Automating ticketing and referral systems streamlines patient handoffs, ensures faster access to care, and creates accurate digital records essential for effective claims management.
Watch how FlowForma Copilot seamlessly structures the claims management process using steps, questions, and rules within seconds.
With FlowForma Process Automation, healthcare providers eliminate manual delays, pre-populate patient data, and integrate with legacy systems, reducing errors and freeing clinician time.
In fact, this major European hospital advanced operational efficiency using the FlowForma Process Automation tool to span multiple IT systems. As a result, the priority shifted from excessive paper-based processes to more efficient clinician-focused processes.
FlowForma Copilot creates an effortless patient onboarding process
Automating patient onboarding not only accelerates the process but also reduces errors and prevents staff from re-entering existing information repeatedly. In fact, FlowForma’s AI Copilot makes onboarding faster and easier with simple digital forms and automated steps.
Automation in medical incident reports and admissions makes things run much smoother. It helps create accurate reports quickly, reducing human errors and saving time. With automated admissions, patients can be checked in faster, and staff can focus more on care, not paperwork. It cuts down on wait times and streamlines the whole process, making healthcare more efficient for everyone.
FlowForma's ready-to-use templates let staff report medication incidents quickly and accurately. Digital forms cut out paperwork and speed up every step, making admissions smoother.
The following are the seven best practices for automated claims processing in healthcare:
Use a centralized claims library to store and manage all approved claims across product lines, regions, and functions. This eliminates version conflicts, reduces duplicate reviews, and ensures teams aren't creating or using inconsistent messaging.
Attach references (e.g., clinical trials, peer-reviewed articles, regulatory submissions) directly to each claim. This supports audit readiness and regulatory defensibility and boosts credibility.
Map out and automate the end-to-end claims review process involving medical, legal, regulatory, and marketing. This enables faster and more compliant approvals with a clean audit trail.
Bring R&D, clinical, regulatory, and commercial teams together early in the product lifecycle to define, validate, and align claims. This ensures claims are clinically sound, legally safe, and market-ready, supporting value-based pricing and reimbursement strategies.
Break claims and supporting content (data points, images, disclaimers) into modular, reusable components. Approved modules can be pulled into region-specific materials without rework. Module creation enables faster asset creation, easier updates, and consistent messaging across global markets.
Ensure claims workflows are built with auditability baked in, version history, access controls, reference tracking, and timestamped approvals. This makes it easy to demonstrate compliance with regulators, especially under frameworks like EU MDR or FDA 21 CFR Part 11.
Regularly review and update claims as clinical data evolves, product features change or healthcare regulations shift.
With FlowForma, regulatory headaches can be transformed into streamlined, strategic execution without the usual bottlenecks. What used to be a burden becomes your competitive edge.
Hear from Blackpool Teaching Hospital NHS Trust as they describe the benefits of deploying FlowForma to automate processes across its organization.
Build and adapt workflows quickly without any IT dependencies. Using easy, templated forms, you can easily configure review steps, data inputs, and approvals.
Clinical data changes, so do claims. FlowForma supports lifecycle tracking, patient scheduled reviews, version sunset dates, and instant notifications to keep everything current.
Powered by Gen AI, FlowForma’s AI Copilot builds processes in no time, for boosted efficiency and productivity.
FlowForma keeps all claims across regions and products in a central library with complete version control and approval history.
Attach clinical studies, regulatory filings, and peer-reviewed references directly to claims. With built-in document management, every claim is traceable and defensible.
From approvals and comments to timestamps, FlowForma tracks every step, ensuring full visibility and ownership.
FlowForma breaks silos reducing rework, misalignment and downstream compliance risks.
Create reusable content blocks (like disclaimers, data points, and visuals) that can be localized without reinventing the wheel. FlowForma ensures consistency without slowing you down.
Now is the time to invest in FlowForma's process automation that analyzes your claims data quickly.
Sign up for a bespoke demo today!
Start by identifying paper-heavy steps like referrals, admissions, and billing. Use FlowForma to build digital forms, automate approval workflows, and connect with existing systems like SharePoint. Pre-fill data where possible to reduce errors. Then, test with real users, roll out in phases and adjust as needed. For an in-depth process, check out this guide on how to automate insurance claims processes.
Healthcare automation replaces manual tasks — like form filling, data entry, or routing — with digital processes to save time, reduce errors, and let staff focus more on patients than paperwork.
Several insurance companies use AI to flag anomalies and speed up approvals.
With FlowForma’s AI Copilot, claims automation becomes faster, more accurate, and easier to manage, ensuring accurate claims data is fed into insurance systems.
FlowForma enables teams to automate medical claims-related steps like referrals, admissions, and reporting without coding or substituting legacy systems.