Revolutionizing Healthcare Claims Adjudication with Custom Solutions

The adjudication of medical claims occurs when an insurance provider reviews them and decides whether to accept or reject them. This is done by cross-analyzing the patient’s benefits and coverage information. By granting easy access to thorough claim adjudication status information, automated medical billing claim adjudication streamlines A/R administration and follow-up processes. Healthcare auto adjudication software can be created to automate the follow-up process for Medicaid and payers, reducing the amount of money it costs to collect while also speeding up the time it takes for a provider to get paid. All these solutions fall under the canopy of healthcare software development companies.  

This blog will discuss how custom healthcare claims adjudication systems can help counter the rising medical claims denial rate and reduce the risk of financial loss. 

Challenges of using a Traditional Claim Adjudication System in Healthcare 

  • Tedious Process: The traditional system for claim adjudication in US healthcare can be a lengthy and cumbersome process. It often involves multiple steps and requires a significant amount of time and effort from both healthcare providers and payers. The manual handling of paperwork, documentation, and repetitive tasks can lead to delays and inefficiencies, resulting in frustrating delays for all parties involved. 
  • Complex Information Acquiring: Claim adjudication requires the acquisition of complex information from various sources, including medical records, billing codes, and insurance policies. The traditional system often relies on manual data entry and verification processes, which can be error-prone. Gathering all the necessary information accurately and efficiently becomes a challenge, potentially leading to delays and inaccuracies in claim processing. 
  • Unstructured Data: The traditional system often faces the challenge of dealing with unstructured data. Medical records, claims forms, and supporting documentation can come in different formats and lack standardized organization, making it difficult to extract relevant information efficiently. This can lead to inefficiencies in data processing, potentially causing delays and errors in claim adjudication. 
  • Stringent Processes: Claim adjudication in the traditional system is subject to strict rules, regulations, and policies set by insurance companies and government entities. These stringent processes can be complex and rigid, leaving little room for flexibility or adaptability. Healthcare providers may find it challenging to navigate through the intricate requirements and guidelines, leading to potential claim denials or delays. 
  • Specific Employee Execution: The traditional system often relies heavily on the expertise and knowledge of specific employees involved in claim adjudication. This dependency on individuals can be problematic, especially when there is a lack of standardized processes and knowledge sharing. If a knowledgeable employee is absent or leaves the organization, it can disrupt the claim adjudication workflow and potentially lead to inconsistencies or delays in processing claims. 

Benefits of a Custom Claims Adjudication System 

  • Multiple Integration options: A custom claims adjudication system offers the benefit of multi-modal integration. It can seamlessly integrate with various systems, such as electronic health records (EHRs), billing systems, and insurance databases. This integration allows for the efficient exchange of information, reducing manual data entry and minimizing errors. It streamlines the claims adjudication process by consolidating relevant data from multiple sources into a single platform. 
  • Interactive Dashboards: These systems come with interactive dashboards that offer a comprehensive view of the claims process. These dashboards present real-time data and key performance indicators (KPIs) in a visually appealing and user-friendly manner. Users can monitor claim statuses, track metrics, and identify bottlenecks or issues that require attention. The interactive nature of the dashboards enables users to drill down into specific details and make informed decisions quickly. 
  • Predictive Modeling: Advanced claims adjudication systems often incorporate predictive modeling capabilities. By leveraging historical claims data and advanced algorithms, the software can identify patterns and trends to predict claim outcomes. Predictive modeling helps in detecting potential fraud, flagging claims that require additional scrutiny, and estimating reimbursement amounts accurately. It enables proactive decision-making and improves the efficiency of the claims adjudication process. 
  • Personalized Scrubbing Technology: This technology automates the process of identifying errors, inconsistencies, and missing information in claims. It applies specific rules and algorithms tailored to the organization’s requirements, ensuring accurate and compliant claims. Personalized scrubbing technology helps reduce manual intervention, minimize errors, and streamline the claims adjudication process. 
  • Data Analytics: It can analyze large volumes of claims data to identify trends, patterns, and outliers. By leveraging data analytics, organizations can gain valuable insights into their claims processes, identify areas for improvement, and make data-driven decisions. It also facilitates cost analysis, and performance evaluation, leading to optimized operations and enhanced financial outcomes. 
  • Data Integration: Our claims adjudication systems facilitate seamless data integration across various systems and platforms by utilizing the power of healthcare APIs. It can efficiently gather data from multiple sources, such as medical records, billing systems, and external databases. This integration enables a holistic view of patient information, billing history, and coverage details, resulting in more accurate and efficient claims adjudication. 
  • Real-time Analytics: Advanced claims adjudication software provides real-time analytics capabilities. It can process and analyze claims data as it is received, allowing for immediate insights and actions. Real-time analytics enable timely decision-making, faster claim processing, and enhanced operational efficiency. It also facilitates real-time monitoring of claims status, enabling proactive intervention and reducing delays. 
  • Optical Character Recognition (OCR): These systems utilize Optical Character Recognition (OCR) technology. OCR converts scanned or printed documents into machine-readable text, making it easier to extract relevant data from claim forms, invoices, and supporting documentation. By automating the data extraction process, OCR reduces manual effort, improves accuracy, and speeds up claims adjudication. 


It is imperative that everyone adapts to new innovations in technology. But as we can see the advantages of a custom claims adjudication system in the healthcare industry cannot be overstated. By implementing a tailored solution, organizations can streamline their claims processing, enhance accuracy, reduce costs, and improve overall operational efficiency. The ability to adapt the system to unique business requirements and regulatory changes ensures a competitive edge in the rapidly evolving healthcare landscape. 

When considering a solution partner to help build a custom claims adjudication system, experience and expertise play a crucial role. This is where Nalashaa stands out as the ideal choice. With over 11 years of dedicated experience in the US healthcare industry, we have developed a deep understanding of its intricacies, challenges, and regulatory demands. Our team of professionals possesses the necessary knowledge and skills to navigate the complex landscape of claims adjudication. In addition to our technical expertise, we are committed to providing exceptional customer service.  

Contact us today and let us embark on this transformative journey together.

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Mitrajit Das

Mitrajit Das

A writer with a keen interest in the Healthcare domain and B2B content marketing. He enjoys writing and creating pieces around the latest Healthcare IT trends using the simplest of words.
Mitrajit Das

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