Best Healthcare Claims Management Software

What is healthcare claims management software?

What are the common features of healthcare claims management software?

What are the benefits of healthcare claims management software?

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.

Software related to healthcare claims management software

Related solutions that can be used together with healthcare claims management software include:

• Medical billing software: Medical organizations use medical billing software to create and manage invoices for the services they provide. Healthcare institutions require certain industry-specific billing features, as medical invoicing varies according to patient diagnostics, treatment, and healthcare coverage. Medical billing software includes support for compliance with health care regulations such as the HIPAA. Additionally, medical billing solutions can increase the accuracy and speed of the billing process for healthcare organizations. Some advanced solutions also provide functionality for revenue management or profitability analysis.
• Medical practice management software: Healthcare organizations use medical practice management software to manage all aspects of their operations, including patient information management, treatment planning and scheduling, and back-office functions such as accounting. This type of software helps doctors with patient treatment management and healthcare administrative personnel with patient influx management. Scaled-down versions of medical practice management can address the needs of small clinics or private practices.
• Revenue cycle management software: Revenue cycle management (RCM) software unifies the business and clinical sides of a health care practice via automation of administrative tasks, pulling of data from EHRs and other hospital information management solutions, and organization of individual RCM processes that already exist. This helps streamline and ease the overall financial processes that exist within a healthcare organization.

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