Inside Mike Esworthy’s Playbook for Tackling Complex Claims

One of the most significant issues with complex claims is that they fall outside the typical “80/20” bucket that most health systems are built to handle. Claims involving the Veterans Affairs (VA), workers’ compensation, or motor vehicle accidents often require a nuanced understanding of eligibility rules, authorization protocols, and payer coordination, which may not be easily managed through standard electronic health record (EHR) workflows. According to data cited in Future Healthcare Today, nearly 20% of veterans who are referred to the VA’s Community Care Network experience delays in care due to administrative errors, such as missing or incorrect insurance information or confusion over eligibility. Veterans were sometimes billed inappropriately or denied care altogether because the system defaulted to billing private insurance or Medicare instead of VA benefits. These errors not only delay payment but also delay treatment, damage trust, and lead to costly rework. To stay ahead of this, hospitals must identify complex claim scenarios early, deploy intelligent systems that flag non-standard payers, and ensure frontline staff are trained to recognize key indicators, such as service-connected conditions or accident-related injuries, during registration.

Healthcare is increasingly complex, and AI, machine learning, and automation are no longer optional — they’re essential tools for hospitals and payers aiming to streamline revenue cycle management, reduce denials, and manage the growing volume of non-standard, exception-based claims. This technology is not intended as a replacement for human expertise, but rather automates repetitive tasks and enhances workflows, allowing staff to focus on resolving the truly complex claims. The result is faster reimbursement, fewer denials, and a more efficient, patient-friendly revenue cycle.

Healthcare leaders today should look at denial rates, time to reimbursement, and overall yield. If you’re spending too much time or manpower chasing 10% of your claims that don’t follow standard paths, which are eating up 30–40% of your resources, that’s a clear case for automation. AI-powered technology tools reduce manual tasks, improve efficiency, workflow, and acceleration, and increase first-pass resolution. Yet for many providers, the upfront investment, implementation complexity, and ongoing maintenance of these tools make in-house solutions unrealistic. That’s why partnering with a specialized tech-enabled company — one with deep data, proprietary AI, and proven results in managing the most complex areas of the revenue cycle—is often the smartest path to drive performance and maximize reimbursement.

Data security and compliance start with smart implementation. AI tools must be embedded in secure environments and governed by robust policies that ensure compliance with HIPAA and payer-specific regulations. Organizations cannot just focus on securing the right partnerships and processes. They must concentrate on obtaining automation that’s auditable, defensible, and aligned with the current industry and regulatory requirements.

Labor shortages are forcing health systems to reassess their operational strategies. The goal now is to allow your staff to focus on areas that require their expertise, rather than routine tasks. That’s where automation and smart workflows come in. For example, at EnableComp we utilize AI to scan claims for missing data to expedite corrections, which frees staff to work the claims that are ready for processing. Strategic outsourcing helps hospitals expand their internal team’s focus on the more standardized commercial claims without compromising quality.

Strategic partnerships are crucial for enabling hospitals and health systems to effectively manage labor shortages, expedite the resolution of all claims, and enhance reimbursement. By working with specialized revenue cycle management (RCM) partners, hospitals gain access to expert support and advanced automation that can streamline the 10–15% of complex claims that fall outside standard workflows, such as those involving the Department of Veterans Affairs (VA), TRICARE, and workers’ compensation. Platforms that integrate with major Electronic Health Records (EHRs) like Epic and Oracle Cerner help automate claims submission, tracking, and denial management, thereby easing administrative burdens and reducing payment timelines.

While hospitals are well-equipped to process standard claims, complex claims often require more in-depth expertise and advanced tools to maximize revenue capture. Strategic RCM partners bring that specialized knowledge and infrastructure, allowing internal teams to stay focused on core operations and commercial claims while offloading the most resource-intensive edge cases to experts who can handle them with speed and precision. These partnerships aren’t just stopgaps — they’re a scalable way to improve cash flow, reduce denials, and ensure timely reimbursement.

VA claims are especially tricky. Generally, the VA only grants one appeal per level, so healthcare providers must get it right the first time. That means staying on top of ever-changing policies and adapting processes in real time. A good RCM partner achieves this by translating regulatory changes into workflow adjustments and effective claim strategies. Whether it’s VA, Medicaid, or workers’ comp, every payer has its quirks, and success comes down to having both the right tech and up-to-date expertise.

We’re going to see more automation in healthcare revenue cycles, but also a deeper focus on analytics and proactive denial management, especially around the appropriateness of care and claim accuracy. The systems that lead will be those that combine AI with deep claims data and specialized expertise. This type of contextual understanding, often referred to as Context-Augmented Generation (CAG), underscores the crucial role of domain knowledge in achieving better financial outcomes. As payer rules continue to shift, adaptability will be essential.

My advice? Don’t chase the latest tech trend. Start with the problem and then build partnerships with organizations that bring purpose-built platforms, proven experience in complex claims, and future-ready solutions. That’s how you scale smarter, improve yield, and ensure the best operational and financial performance.

The convergence of AI with domain-specific knowledge is going to be a game-changer for improving financial performance. General AI tools are insufficient. But purpose-built CAG solutions that understand the nuances of complex claims and denials are where the real gains are. Additionally, implement better overall processes, such as front-end patient eligibility and payer mapping. Those investments will massively reduce denials and improve revenue integrity over time.