In the ever-changing world of healthcare, few things create as much frustration for providers as claim submission errors. Submitting a claim may look straightforward on paper—collect patient details, code the diagnosis, and send it to the payer. But in reality, it’s an obstacle course filled with coding updates, payer rule changes, patient financial responsibility complexities, and technological hurdles.
As we step into 2025, the industry is facing both old and new challenges when it comes to submitting clean claims. From evolving compliance requirements to AI-driven claim scrubbing, the dynamics of revenue cycle management (RCM) are shifting rapidly. Providers, coders, and billing teams must not only stay updated but also be agile in how they adapt.
In this newsletter, we’ll take a deep dive into the top claim submission challenges in 2025, explore why they matter, and provide actionable solutions to overcome them—so your organization can protect its bottom line, improve collections, and reduce denials.
Why Claim Submission Still Matters More Than Ever
Before diving into the challenges, let’s talk about why claim submission is still the backbone of revenue cycle performance. A “clean claim” is one that passes through payer systems the first time, without errors or rejections. Clean claim rates directly impact cash flow, provider satisfaction, and patient trust.
In fact, a recent industry survey showed that:
- Nearly 20% of claims are denied or delayed on the first submission.
- Claim rework can cost providers an additional $25–$40 per claim.
- Rejected claims lead to delays in patient collections, affecting patient satisfaction scores.
In 2025, payers are doubling down on automation, AI-driven audits, and stricter policy compliance. That means even the smallest errors in claim submission can lead to significant revenue leakage if not managed properly.
Top Claim Submission Challenges in 2025
1. Constantly Changing Payer Rules
Payers are notorious for making frequent adjustments to their policies—everything from coverage limitations to modifier requirements. In 2025, insurers are relying on AI claim adjudication engines that catch even minor discrepancies.
Why it’s a Problem:
- Providers struggle to keep up with the constant stream of policy updates.
- Inconsistent rules across payers increase administrative burden.
- Manual updates in billing software often lag behind real-time payer changes.
How to Overcome It:
- Invest in payer rule engines that update automatically.
- Train billing staff monthly on payer-specific updates.
- Partner with clearinghouses that have real-time integration with payer systems.
- Create a “payer playbook” that coders and billers can reference for top payers.
2. ICD-11 Transition Complexities
2025 is the year ICD-11 starts becoming the global standard, with many payers adopting it in parallel with ICD-10. This dual coding landscape is creating confusion among providers.
Why it’s a Problem:
- ICD-11 introduces new categories, digital-friendly coding, and more detailed specificity.
- Dual usage of ICD-10 and ICD-11 creates compatibility issues in billing systems.
- Many coders are still adapting to the new terminology.
How to Overcome It:
- Provide continuous ICD-11 training for coding teams.
- Upgrade EHRs and practice management systems to ensure ICD-11 compatibility.
- Use AI-assisted coding tools that map ICD-10 to ICD-11 efficiently.
- Implement audits specifically focused on coding transitions.
3. Prior Authorization Delays
Prior authorization remains one of the biggest bottlenecks in claim submission—and 2025 hasn’t eliminated the problem. In fact, with more procedures now requiring prior approval, delays are worse.
Why it’s a Problem:
- Delays lead to care postponements and frustrated patients.
- Denials due to missing or incorrect authorization numbers.
- Increased staff workload to track and follow up on authorizations.
How to Overcome It:
- Automate prior authorization requests using payer portals and APIs.
- Assign a dedicated authorization specialist within billing teams.
- Create an internal dashboard to track pending authorizations in real time.
- Educate patients about their role in authorization compliance.
4. Incomplete or Inaccurate Patient Information
Even in 2025, some of the most common claim rejections happen because of basic errors—like misspelled names, outdated insurance details, or missing demographic information.
Why it’s a Problem:
- Front-end errors snowball into billing denials.
- Patients switch insurance plans more frequently now, thanks to digital health marketplaces.
- Manual data entry mistakes still plague front-office operations.
How to Overcome It:
- Adopt real-time eligibility verification tools.
- Train front-desk staff to double-check patient details at every visit.
- Use automated patient intake solutions with self-service kiosks.
- Sync EHR and billing platforms to avoid duplicate entries.
5. Medical Necessity Denials
Payers in 2025 are stricter than ever about ensuring that procedures meet “medical necessity” criteria. Automated claim reviews now flag services that don’t align with evidence-based guidelines.
Why it’s a Problem:
- Claims denied for lack of supporting documentation.
- Increased burden on physicians to justify clinical decisions.
- Patients stuck with unexpected out-of-pocket expenses.
How to Overcome It:
- Incorporate clinical decision support tools in EHRs.
- Train providers on documenting medical necessity in clear, payer-friendly language.
- Conduct pre-bill audits to ensure proper justification is attached.
- Appeal aggressively when denials are not justified.
6. Coordination of Benefits (COB) Confusion
With patients holding multiple insurance policies more than ever (employer-sponsored, Medicare Advantage, supplemental), COB issues remain a leading reason for claim rejections.
Why it’s a Problem:
- Incorrect identification of primary vs. secondary coverage.
- Payment delays while payers determine responsibility.
- Patient dissatisfaction due to billing confusion.
How to Overcome It:
- Verify COB status at every patient encounter.
- Train staff to ask patients about new or secondary insurance.
- Use clearinghouse tools that validate COB automatically.
- Establish a workflow for resolving COB-related denials quickly.
7. Bundling and Unbundling Errors
In 2025, payer AI systems are exceptionally good at detecting incorrect bundling of procedures. Submitting procedures separately when they should be bundled—or vice versa—triggers denials.
Why it’s a Problem:
- Loss of revenue due to undercoding.
- Denials for overbilling due to unbundling.
- Increased payer scrutiny leading to audits.
How to Overcome It:
- Regularly train coding staff on National Correct Coding Initiative (NCCI)
- Leverage AI-powered coding software that flags bundling issues before submission.
- Conduct routine internal audits for high-volume procedures.
8. Technology Integration Gaps
While technology has improved RCM workflows, many practices in 2025 still struggle with integration issues between EHRs, billing systems, clearinghouses, and payer portals.
Why it’s a Problem:
- Duplicate data entry leads to errors.
- Lack of visibility across the claim lifecycle.
- High IT costs for system upgrades and maintenance.
How to Overcome It:
- Invest in end-to-end RCM platforms with seamless integration.
- Use APIs to connect disparate systems.
- Demand vendor accountability for timely updates and bug fixes.
- Prioritize interoperability when evaluating new solutions.
9. AI-Driven Claim Scrutiny
Payers in 2025 use advanced AI models to analyze claims, detect fraud, and flag anomalies. While this helps reduce abuse, it also creates challenges for legitimate providers.
Why it’s a Problem:
- Higher rate of claim reviews, even for valid submissions.
- Time-consuming documentation requests from payers.
- Increased risk of audits for outlier billing patterns.
How to Overcome It:
- Standardize coding practices across your organization.
- Use predictive analytics to flag claims that may be at higher risk of denial.
- Maintain robust documentation to support billing decisions.
- Appeal unjustified denials with strong clinical backing.
10. Patient Cost-Sharing Complexities
High-deductible health plans (HDHPs) continue to grow in popularity. This means more patients are financially responsible for larger portions of their bills, complicating claim submission and collections.
Why it’s a Problem:
- Confusion over what payers cover vs. what patients owe.
- Increased patient billing inquiries and disputes.
- Rising patient bad debt due to affordability challenges.
How to Overcome It:
- Provide clear financial counseling at the point of service.
- Offer upfront cost estimates for procedures.
- Implement flexible payment plans to improve patient collections.
- Educate patients on their insurance benefits before care is delivered.
The Future of Claim Submission
The challenges of 2025 may feel daunting, but the future is promising. Innovations like block chain-based claim verification, AI-driven coding assistants, and real-time payer-provider collaboration tools are on the horizon.
Healthcare organizations that embrace automation, invest in staff training, and foster payer-provider collaboration will see the highest clean claim rates and the lowest denial percentages. The key is to treat claim submission as a strategic function—not just a back-office task.
Claim submission in 2025 is no longer just about sending bills—it’s about navigating a complex digital ecosystem where accuracy, compliance, and speed determine financial success. The organizations that thrive will be the ones that:
- Stay proactive about payer and coding changes.
- Leverage technology without losing the human touch.
- Empower staff with training and real-time tools.
- Build transparent communication channels with both payers and patients.
By tackling these top challenges head-on, you can transform claim submission from a point of frustration into a competitive advantage that fuels growth and sustainability.