Due to ever-rising healthcare costs and the increasing complexity of today’s billing methods, claims processing has become a substantial burden on many healthcare providers and plan payers.
In addition to the hours of administrative work it can take to resolve a single medical claim, the claims adjudication process is estimated to cost providers more than $25 billion a year — and that’s not even including the expenses borne by other parties, such as health plans and the payers who sponsor them.
As these waste numbers climb year after year, the answer to today’s challenges becomes clear: comprehensive risk reduction in the form of defensible healthcare claims management.
By investing in claims management built on transparency, accuracy, and compliance, today’s plan payers and their sponsors can transform their billing and payment processes into well-oiled machines that reduce disputes, ensure fair reimbursement, and save money for all parties in the healthcare journey.
Below, learn more about the strategies required to make it happen — and how the data-driven payment integrity solutions from Vālenz Health® take the burden off your shoulders to simplify the entire healthcare experience.
Claims processing and management has long been an integral part of the healthcare system, but ongoing industry developments and trends have recently shed a light on just how crucial proper handling of this process is.
First, there’s the ever-rising costs of healthcare in general. Since 2000, the price of medical care in the United States has increased by 121.3%, significantly outpacing the cost increase for all consumer goods and services during the same period (86.1%). Since 2021, the top 20 high-cost conditions in healthcare have experienced a 38% average increase in cost, leading many employers to cite “managing high-cost claims” as their greatest priority for 2026.
At the same time that claims cost themselves are increasing, so is the prevalence of fraud, waste, and abuse (FWA) within those claims. The National Health Care Anti-Fraud Association estimates that the healthcare industry experiences more than $300 billion in losses due to fraud each year. In 2023 alone, more than $1.8 billion was paid in fraud settlements under the False Claims Act.
Of course, there is also the cost of necessary compliance with regulations like the No Surprises Act. Between 2022 and 2024, the independent dispute resolution process associated with the NSA totaled more than $5 billion, a financial burden mostly borne by the plan payers who disproportionately lose when final IDR determinations are made.
As a result, today’s claims teams are under increasing pressure to identify and resolve errors on a larger, faster scale than ever before — a pressure that is already taking its toll.
According to the Experian Health 2025 State of Claims report, 54% of providers say claim errors are increasing, with 68% of them reporting that submitting “clean” claims is more challenging than it was just a year ago. At the same time, 41% of providers say that 10% or more of their claims have been denied in the last year, a process that slows down the entire claims management journey for all involved.
Recognizing these challenges and the opportunities for improvement, 59% of providers report they plan to invest in claims processing and/or denial reduction technology in the next six months — a priority that has been echoed by many of our self-funded clients here at Valenz, as well.
As stakeholders across the healthcare continuum look to improve their claims management in the year to come, it’s important to recognize the major gaps that traditional claims processing has created — gaps that allow for the financial and administrative risks discussed above.
By implementing a few strategic improvements, today’s stakeholders can build a more defensible claims process suited for the challenges of the modern healthcare system, eliminating those risks with a strategy backed by data integrity, clinical validation, regulatory alignment, and documentation transparency.
(To learn more about how Valenz employs these strategies in our claims processing solutions, connect with one of our team members today.)
Historically, manual review has been the only option for the claims review process, requiring clinical and bill review teams to spend hours combing through thousands of claims to identify errors, confirm coding, and verify authorization, among other tasks.
And, while automated review and other AI-powered capabilities have become more powerful over the last decade, the uptake of these programs is still slow, with 47% of providers reporting they still conduct completely manual review of claims.
Automated claims review and processing holds great promise for the healthcare industry. According to a report by Accenture, key clinical health AI applications could potentially create $150 billion in annual savings for the U.S. healthcare industry by 2026, with estimated savings of $18 billion for administrative workflows and $17 billion for fraud detection.
However, like all artificial intelligence, deploying AI in the healthcare claims management process requires a measured approach — one that combines automated review with oversight of clinically trained, human experts.
Here at Valenz, that approach involves:
In short, automation such as AI can (and should) be an integral part of modern healthcare claims processing, as long as it’s deployed in a strategic manner. By combining AI review and expert human intelligence into one complementary partnership, stakeholders can support more precise, efficient savings across the entire claims journey — without falling victim to the risks of entirely AI-led processing.
Due to the vast volume and complexity of claims received today, many claims management strategies take a reactive approach, waiting until claims are submitted to review for payment discrepancies and billing errors.
Unfortunately, by waiting until the payment stage to review claims, these strategies miss out on key opportunities to minimize costs and streamline efficiency earlier in the claim lifecycle — before payment is made and, in some cases, before services are even rendered.
To identify errors and capture cost savings more effectively, today’s claims management processes need a full-cycle approach. By reviewing claims before, during, and after payment is made, clinical and billing teams can not only catch errors before they lead to costly overpayments; they can also minimize the chance of balance billing for patients, improving the experience for the members at the heart of the plan.
At Valenz, we refer to this cycle as the Claim Cost Arc℠:
By employing strategic payment integrity solutions throughout every stage of the claims review process, we stop billing and coding errors before they cause costly damage for both the plan payer and the plan member, not to mention the administrative time and energy required from claims teams.
By combining this early intervention with the AI-powered review discussed above, the Valenz Payment Integrity team is also able to identify opportunities for improvement in the overall healthcare claims management process — improvements that can deployed while a claim is in flight to make the entire review journey easier for all involved.
The result: Meaningful cost containment for both plans and members, such as the $900,000 in savings we delivered on a single, high-cost brain surgery claim — before the surgery was even initiated.
Breaking Down Data Silos for Better Claims Visibility
Finally, one of the biggest improvements that can be made to the modern healthcare claims management process is replacing an individualistic approach with a collaborative one, in which every member of the claims process works together to deliver maximum cost savings and more efficient claims processing.
Historically, claims management has been a siloed process where each party holds its internal pricing and care data close to its chest with the goal of maximizing or minimizing payments, depending on which side of the system they’re on. This approach has done little but add unnecessary obstacles to the process, stagnating the review process as each stakeholder goes back and forth requesting claims and care data, reviewing documentation, confirming care authorization, and more.
Here at Valenz, we think it should be done differently: through an integrated system that freely and regularly shares data across stakeholder boundaries to break down silos and improve the healthcare experience for all involved.
By sharing both pricing and care data early and often throughout a member’s care journey, we work with providers and payers to eliminate billing errors before they hit the claim stage, saving significant money, time, and effort for all involved. With an ongoing, positive exchange of data between all sides of the claims management process, our payment integrity solutions bring increased visibility to provider billing patterns, common coding errors, and other claims trends impacting efficiency and effectiveness.
As a result, our integrated strategy brings industry-leading savings to our clients, including $461,000 on a single drug claim for one member.
In today’s complex healthcare environment, successful claims management starts with a defensible strategy — one that’s backed by data integrity, clinical validation, regulatory alignment, and documentation transparency.
With its unique full-cycle approach, the Valenz Payment Integrity solution suite fits the bill.
Our comprehensive claims management services are backed every step of the way by all the data and clinical expertise needed to reduce errors, avoid provider appeals, and deliver faster, fairer reimbursements for our clients.
We achieve it all with solutions applied throughout a claim’s lifecycle, including:
Learn more about this solution suite — and how our integrated approach improves the claims management process for every party in the healthcare continuum — by contacting one of our team members today.
With the healthcare claims management process growing ever more complex and demanding more time and energy from involved parties, traditional claims processing strategies have proven they can no longer keep up. Indeed, without significant changes to how the entire system works, these processes will continue to waste immense resources for plans, payers, providers, and members — exacerbating the already sky-high costs of the modern healthcare experience.
Fortunately, there is a better way.
By integrating strategies such as automation into a proactive, collaborative claims process, today’s stakeholders can quickly and efficiently transform their claims management operations for a brighter future. And, by integrating full-cycle payment integrity solutions like those from Valenz, you can engage early and often to not only reduce claims challenges — but also deliver smarter, better, faster healthcare that improves outcomes and experiences for plan members.
For more information about how the Valenz Payment Integrity solutions can improve your healthcare claims management process, contact our team members anytime below.