Health claims processors manually re-key data from 50,000 medical bills monthly because adjudication systems can't read provider documents

HIPAA Compliance is Non-Negotiable

Health claims contain Protected Health Information (PHI): diagnoses, treatment details, provider names, patient identifiers. HIPAA requires strict controls: encryption at rest and in transit, access logging, breach notification within 60 days, Business Associate Agreements with all vendors, and regular compliance audits.

Many claims automation platforms can't meet HIPAA requirements: data stored in non-compliant cloud environments, insufficient access controls, no audit trails, and vendors unwilling to sign BAAs. This forces health insurers to continue manual processing because automated alternatives aren't compliant.

Regure is HIPAA compliant with enterprise-grade security, BAA signing standard for all health clients, end-to-end encryption (AES-256 at rest, TLS 1.3 in transit), role-based access controls with PHI restrictions, and immutable audit trails logging every document access. Compliance isn't a feature — it's the foundation.

Extreme Volume Requires Straight-Through Processing

Mid-size health insurers process 100,000+ claims monthly. Large insurers process 1,000,000+ claims monthly. At this volume, every manual touchpoint is expensive. Industry benchmarks target 80%+ auto-adjudication (claims paid without human review).

Straight-through processing requires: automated document classification (medical bills vs. EOBs vs. pre-authorization forms), data extraction with 98%+ accuracy (CPT codes, diagnosis codes, provider IDs, service dates, billed amounts), duplicate claim detection, coordination of benefits checking, and network provider verification.

Manual processing costs $8-12 per claim in labor. Automated processing costs $3-5 per claim. For a 500,000 claim/month insurer, automation saves $2.5-4.5M monthly. These savings flow directly to bottom line and allow insurers to meet Medical Loss Ratio requirements while remaining profitable.

Complex Adjudication Rules and Medical Coding

Health claims adjudication involves thousands of rules: CPT code allowed amounts per network tier, diagnosis code medical necessity validation, bundled procedure detection (can't bill separately for procedures included in another), duplicate service checking (same procedure billed twice), and coordination of benefits when patient has multiple insurers.

These rules change constantly: CMS updates CPT/ICD codes annually, network contracts renegotiate rates quarterly, state mandates require coverage changes, and plan designs vary per employer group. Keeping adjudication systems current requires constant maintenance.

Regure doesn't replace adjudication systems (Facets, QNXT, HealthRules) — it feeds them with clean, structured data. Medical bills arrive as scanned PDFs or faxed images. Regure extracts CPT codes, diagnosis codes, service dates, and billed amounts with 98% accuracy, then validates against basic rules before passing to adjudication. This pre-validation reduces adjudication errors and rework.

Provider Document Chaos and Format Variations

Health claims arrive from 50,000+ providers nationwide: hospitals, physician practices, labs, imaging centers, pharmacies, durable medical equipment suppliers. Each provider uses different billing formats: CMS-1500 forms (professional services), UB-04 forms (institutional services), proprietary hospital billing systems, and handwritten documentation.

Format variations create processing nightmares: fields in different locations across forms, inconsistent abbreviations, missing required data, illegible handwriting, and fax artifacts that obscure text. Manual data entry from these documents averages 5-8 minutes per claim and creates 12-15% error rates.

Regure's medical document OCR is trained on 5M+ provider bills across all 50 states. The system recognizes CMS-1500 and UB-04 form layouts automatically, extracts data with 98% accuracy even from poor-quality faxes, and validates extracted data against formatting rules (NPI numbers are 10 digits, CPT codes are 5 characters, dates are valid). Errors flag for human review instead of causing downstream adjudication failures. Manual data entry reduces by 78%.

1. HIPAA-Compliant Document Processing

Health claims contain Protected Health Information (PHI) requiring strict HIPAA controls: encryption, access logging, breach notification procedures, and Business Associate Agreements. Many automation platforms can't meet these requirements.

Regure is purpose-built for HIPAA compliance: enterprise-grade security with independently verified controls, BAA signing standard for all health clients, AES-256 encryption at rest, TLS 1.3 encryption in transit, role-based access controls with PHI restrictions, and immutable audit trails logging every document access with user ID, timestamp, and action taken.

Document retention follows HIPAA requirements: claims records retained for 6 years minimum (longer if state law requires), automatic purge workflows after retention periods expire, and secure deletion with cryptographic verification. Compliance isn't a checkbox — it's embedded in the platform architecture.

2. Medical Coding Extraction at Scale

Health claims adjudication requires accurate extraction of medical codes: CPT procedure codes (5-character alphanumeric), ICD diagnosis codes (up to 7 characters), HCPCS codes (5 characters), revenue codes (4 digits), and modifier codes (2 characters). Errors in any code create adjudication failures requiring manual rework.

Regure's medical coding AI is trained on 5M+ provider bills and achieves 98% accuracy on code extraction from CMS-1500 and UB-04 forms — even from poor-quality faxes, handwritten entries, and non-standard provider formats. Extracted codes validate against CMS code sets to catch invalid codes before adjudication.

For medical necessity validation, Regure cross-references CPT procedure codes with ICD diagnosis codes to flag potential medical necessity issues: procedure doesn't match diagnosis, diagnosis doesn't support medical necessity for requested procedure, or diagnosis code is non-specific (e.g., "unspecified" codes flagging for additional documentation).

This pre-validation reduces adjudication error rates from 15% (manual entry) to under 2% (automated extraction with validation). For a 500,000 claim/month insurer, this prevents 65,000 claim errors monthly requiring rework.

3. Duplicate Claim Detection

Duplicate claims occur when: providers submit same claim multiple times, patients file claims already paid by primary insurer, or system errors create duplicate claim records. Paying duplicates wastes millions annually and creates fraud liability.

Regure detects duplicates using multi-factor matching: patient identifier + service date + provider NPI + CPT code = duplicate. Fuzzy matching catches near-duplicates: same patient/provider/date but slightly different billed amounts (one claim for $150.00, another for $150). These near-duplicates flag as potential billing errors or fraud attempts.

Detection happens at intake before adjudication begins. Duplicate claims auto-deny with reason codes ("duplicate of claim #ABC123 paid on 10/15/2025"). This prevents payment and stops provider follow-up questioning why claims were paid twice.

4. Coordination of Benefits Automation

When patients have multiple insurance (e.g., covered by employer plan and spouse's plan), coordination of benefits (COB) determines which insurer pays first. Primary pays first, secondary pays remaining allowed amounts up to their own limits. Manual COB processing is complex and error-prone.

Regure automates COB workflows: when EOB from primary insurer arrives, extract primary paid amount and patient responsibility, calculate secondary payer responsibility based on plan rules, and auto-adjudicate secondary claim if within allowed amounts. Claims requiring manual review flag based on configurable thresholds.

COB errors create patient billing disputes ("I paid my copay, why am I getting another bill?") and provider frustration ("which insurer do I bill for the remaining balance?"). Automated COB reduces billing disputes by 64% and improves provider satisfaction.

5. Provider Network Verification

Claims must verify providers are in-network before applying in-network benefit rates. Out-of-network providers receive different (usually lower) reimbursement rates and patients have higher cost-sharing. Verifying network status manually for every claim is impractical at high volumes.

Regure integrates with provider network databases: extract provider NPI from claim, lookup network status as of service date (network participation changes over time), and apply appropriate benefit tier. Multi-tier networks (Tier 1/2/3 with different reimbursement rates) auto-classify based on provider contracts.

Network status also affects prior authorization requirements: some procedures require pre-auth for out-of-network providers but not in-network. Regure flags claims requiring retroactive pre-auth review based on provider network status and procedure codes.

6. Integration with Adjudication Systems

Health insurers use adjudication platforms (Facets, QNXT, HealthRules Payer, TriZetto) for claims processing rules and payment calculation. Regure doesn't replace these systems — it feeds them with clean, structured data extracted from provider documents.

Integration is bi-directional: claim data from provider bills exports to adjudication systems via HL7, X12 837, or API. Adjudication decisions (paid/denied/pending, paid amounts, denial reasons) import back into Regure for provider correspondence and audit trails.

This integration eliminates duplicate data entry: claims processors don't manually key data into adjudication systems, and adjudication results don't require manual entry into document management systems. End-to-end automation from provider bill receipt through payment posting. See Middle East digital transformation case studies for large-scale health claims automation examples.