6 Ways AI & Automation Drive Claims Accuracy for Health Plans

Health plan payers process billions of claims each year. In fact, CMS reported more than 1.1 billion Medicare Fee-for-Service (FFS) claims in 2024.¹ With this scale, even a small percentage of errors translates into billions of dollars lost annually.   

As of 2025, the challenge isn’t just processing claims fast; it's about:   

• Ensuring accuracy under evolving CMS regulations  

• Preventing fraud, waste, and abuse (FWA)  

• Complying with new interoperability and transparency rules  

• Managing Medicare Advantage audit readiness  

• Leveraging AI for real-time insights and automation   

In this blog post, we break down the factors affecting payment accuracy, the role of AI and automation, and how Mirra Health Care’s claims adjudication services ensure compliance and efficiency for health plans.    

4 Challenges Still Affecting Payment Accuracy in 2025

Several factors can affect payment accuracy. Here are some of them:   

Complex & Evolving Payment Rules

A tangled web of fee schedules, provider contracts, and regional cost variations shapes healthcare reimbursement. With CMS’s 2024 rules on prior authorization digitization and prescription drug transparency, claims adjudication now requires processing against an even broader set of compliance variables.   

Another factor that adds to the complexity of claim payment is member seasonal geolocation. Some health plans may cover members who travel or live in different regions throughout the year, and this can impact the cost of healthcare services. For instance, if a member travels to an area where healthcare services are more expensive, the cost of their care may be higher, which can impact the amount of reimbursement provided by the health plan payor.  

Look into Strategies to Lower Claims Adjudication Costs 

Coding Errors

Incorrect medical coding remains one of the most significant contributors to claim denials and overpayments. For example, miscoding a colonoscopy screening as a diagnostic procedure could completely change coverage and patient responsibility.  

Today, AI and medical billing services are increasingly being used to validate codes in real time, using natural language processing (NLP) to reconcile provider notes with selected codes.  

Poor Interoperability

When two organizations come together, the different technology platforms they use may be incompatible. This can lead to redundancies and inconsistencies in claims processing, which can have a significant impact on the quality of care provided to members.  

In addition to the challenges of organization consolidation, many payer departments operate in silos. For instance, claims processing, provider network management, and member services may operate independently, each with its own set of tools and systems. This lack of coordination can lead to duplication of effort and errors, ultimately leading to higher costs and lower quality of care management services.  

Audit Requirements

In January 2023, CMS issued the Medicare Advantage RADV Final Rule (CMS‑4185‑F2), which took effect for Payment Year 2018 forward. This allows CMS to use extrapolation of audit findings to recover overpayments at scale.²   

In 2024, CMS also finalized its Interoperability and Prior Authorization Rule, requiring Medicare Advantage and Medicaid plans to implement FHIR APIs to share enrollee data and to process digital prior authorization requests. These updates raise the compliance bar and make digital audit readiness and real‑time interoperability critical for health plans.   

How Can Automation Improve Payment Accuracy?

Automation can help streamline claims processing by doing the following:   

• AI-driven coding validation  

Ensures claim codes match actual medical documentation.    

• Predictive fraud, waste & abuse (FWA) detection  

Identifies suspicious billing patterns before payments are issued.   

• RPA (Robotic Process Automation)  

Eliminates manual re-keying in TPA Premium Billing and reconciles LIS/SSA payments automatically.    

• FHIR-based interoperability  

Ensures real-time, error-free data exchange between payers, providers, and regulators.    

• Audit-preparation AI  

Auto-generates RADV/CMS-compliant documentation.  

• GenAI chatbots  

Handle provider inquiries, prior authorizations, and member claim-status requests without human delays.  

Moreover, advanced machine learning algorithms, real-time analytics, and predictive modeling can help payers identify high-risk claims and providers, detect potentially fraudulent claims, and provide instant feedback on the accuracy of payments.  

These advances underscore how critical technology has become for payers. For more in‑depth discussions, visit our Insights hub.   

How Mirra’s Technology Can Help Health Plans Ensure Smooth Claims Processing  

Mirra Health Care is your trusted partner for seamless claims processing. We provide AI-powered claims adjudication and TPA Premium Billing services that are purpose-built for 2026 compliance.   

• Enhanced Information Accuracy – AI-backed validation minimizes coding errors and ensures claim accuracy at intake.  

• Transparent Audit Trails – Built-in RADV/CMS-ready documentation.  

• Intelligent Payment Tracking – Automated reconciliation with LIS and SSA.  

• Fraud & Abuse Prevention – Predictive analytics flag suspicious billing patterns.  

• Future-Proof Compliance – Ready for FHIR-based interoperability and evolving CMS rules.  

• Efficient Medical Billing Services – End-to-end support covering claim capture, validation, and adjustment, resulting in fewer denials and faster reimbursements.  

Mirra’s Results in Action 

In 2024, Mirra helped a large regional health plan reduce Medicare Advantage claim error rates by 23% and cut denial turnaround times by 18% through automated audit trails and FHIR‑ready integrations. These results highlight how an AI‑powered TPA Premium Billing + claims adjudication solution drives measurable impact.  

With Mirra, payers don’t just process claims; they achieve accuracy, compliance, and cost efficiency at scale.   

For in depth understanding read on Claims Adjudication: A Strategic Guide for Health Plan Executives 

Visit Mirra Healthcare’s website to explore their Medicare in a box solution and Claims Adjudication service, and learn how it can help improve the accuracy of your claims processing system. For more information, contact us.  

References: 

1. Centers for Medicare & Medicaid Services  

2. Medicare Advantage Risk Adjustment Data Validation Final Rule (CMS-4185-F2) Fact Sheet