Why Every Claim Tells the Story of Your Compliance Posture
By Sesha Mudunuri, Chief Operating Officer, Executive Vice President
Claims adjudication isn’t just about paying claims—it’s where your entire operation is put to the test. In today’s regulatory environment, the regulators and auditors aren’t only asking whether a claim was paid—they’re scrutinizing how and. Every upstream process—eligibility, provider configuration, fee schedules—shows up in your claims data. When those processes aren’t tightly managed, your claims system becomes the spotlight exposing every operational gap.
Claims adjudication is the mirror of your operational governance—every decision made upstream in eligibility, provider setup, and pricing logic shows up in how a claim performs downstream.
In this 90-second Leadership Insights video, learn more:
The Critical Connect: Claims and Compliance
Too often, health plans treat claims and compliance as two separate functions—operations on one side, audit readiness on the other. But in reality, they’re inextricably linked. Every claim tells the story of your compliance posture.
When compliance isn’t embedded across processes, errors multiply: claim denials rise, member complaints increase, and audit risks grow. On the other hand, when compliance is integrated into operations, adjudication becomes smoother, faster, and more accurate.
Where Gaps Begin—and How to Close Them
Operational misalignment typically stems from issues that seem small on the surface:
Disconnected workflows between claims and compliance teams
Delayed updates to provider data or fee schedules
Lack of real-time visibility into eligibility or configuration changes
Each of these can cascade into denials, payment delays, or compliance findings. The key is early alignment. By embedding compliance checks directly into operational workflows, health plans can resolve root issues before they reach the claim system.
The Bottom Line: Where Performance and Compliance Meet
Claims adjudication is the reflection of your operational health. When compliance and operations work in sync, health plans don’t just reduce risk—they elevate performance across the board.
Imagenet helps healthcare payers close the gap between operations and compliance—combining intelligent automation, proven workflows, and expert oversight to drive accuracy, efficiency, and trust at every step.
Our intelligent solutions include:
Digital Mailroom – Transform unstructured content into clean, actionable data—fast.
Claims Adjudication – Accelerate accuracy and compliance from intake through reconciliation.
Member Communications & Reconciliation – Ensure timely, accurate, and compliant member interactions.
Contact Center – Fully integrated, tech-driven support that improves experience and efficiency.