Revenue Optimization
Claims Management & Optimization
Claims management covers everything between a coded encounter and an adjudicated payment: scrubbing against payer edits, electronic submission, status tracking, and rapid correction of rejections. Catching an error before submission costs a fraction of reworking a denial after it.
What’s included
- Pre-submission scrubbing — Automated validation against payer-specific rules, NCCI edits and medical necessity before submission.
- Electronic submission — Secure electronic submission to all major payers with clearinghouse acknowledgement tracking.
- Real-time monitoring — Continuous claim status tracking with alerts on anything stalled or rejected.
- Rapid error resolution — Rejections are identified, corrected and resubmitted in days, not weeks.
- Performance analytics — Dashboards showing acceptance rate, rejection reasons and payer-level trends.
- Process optimization — Data-driven changes to submission practice that lift clean claim rate over time.
The problem
Where claims management goes wrong
High rejection rates from avoidable data and eligibility errors
No visibility into where a claim sits once it is submitted
Manual submission processes introducing delay and error
Denial patterns invisible because nobody aggregates reason codes
Claims abandoned past the filing deadline and written off
Rework consuming staff time that clean submission would have saved
How it works
Our claims management process
Claim scrubbing
Pre-submission validation checks coding accuracy, demographics, eligibility and compliance requirements.
Electronic submission
Claims are transmitted electronically with correct formatting and any required attachments.
Status tracking
We monitor adjudication in real time and act on anything that stalls or rejects.
Performance analysis
Aggregated data identifies the recurring causes of rejection so submission practice improves.
Outcomes
What changes for your practice
We baseline these during the free audit so improvement is measured against your actual starting point, not an industry average.
Get your free audit- Higher first-pass acceptance rates
- Fewer rejections and denials reaching your AR
- Faster reimbursement and improved cash flow
- Real-time claim status visibility
- Errors caught before submission, not after
- Filing deadlines tracked so nothing expires
Questions
Claims Management FAQ
Last updated August 20, 2026
Reviewed by a certified coding leadClaim scrubbing is automated pre-submission checking for errors — coding accuracy, patient demographics, insurance details and compliance requirements. It matters because catching an error before submission is dramatically cheaper than reworking a denial: MGMA puts rework at roughly $25 within three days versus $118 after 30.
A rejection happens before adjudication — the clearinghouse or payer refuses the claim for a format or data error, and it never enters the payer's system. A denial happens after adjudication, when the payer processes the claim and declines payment. Rejections are usually fixed and resubmitted in days; denials require appeal.
We use integrated clearinghouse connections and direct payer portals to track claims through adjudication. You get dashboard access showing submission status, processing stage and anything requiring attention, rather than waiting for a monthly report.
Rejections are flagged immediately, root-caused, corrected and resubmitted. We also aggregate rejection reasons by payer so recurring causes get fixed at the source instead of being handled one claim at a time.
Terms used on this page
Clean Claim
A clean claim is a claim that passes payer adjudication and is paid on first submission, without rejection, denial or a request for additional information. Clean claim rate — the percentage of claims meeting that standard — is the most direct measure of whether a billing operation is working.
Claim Scrubbing
Claim scrubbing is the automated review of a claim before submission, checking it against payer rules, code edits and formatting requirements to catch errors that would cause a rejection or denial. It runs after coding and before transmission, and it is the cheapest possible point of correction.
Clearinghouse
A clearinghouse is an intermediary that receives claims from providers, validates and reformats them into each payer's required electronic standard, and routes them onward. It also returns acknowledgements, rejections and electronic remittance advice, acting as the single connection point to hundreds of payers.
Rejection
A rejection is a claim stopped before adjudication — by the clearinghouse or the payer's intake system — for a format, data or eligibility error. Because it never entered adjudication, it carries no appeal rights and does not appear in payer claim status. It must be corrected and resubmitted.
Still deciding how to run billing at all? Compare in-house against outsourced or read the full set of comparisons.
Find out what your denials are costing you
A free billing audit reviews your denial rate, AR aging and clean claim rate against industry benchmarks. Takes about two minutes to request. No sales pitch.
No setup fees · You pay when we collect · Pricing from 3% of net collections