Choosing a Complex Claims Partner: What to Measure and What to Watch For

Workers' compensation, motor vehicle accident, and Veterans Affairs claims make up a small but demanding corner of hospital revenue cycles. They call for deep regulatory knowledge, specialized billing workflows, and consistent follow-through. And while their volume may be modest, the financial and compliance stakes are anything but.  

Many hospitals manage these claims with small teams using billing systems that were never designed for this level of complexity, requiring staff to manually track down auto insurance carriers, workers' comp adjusters, billing addresses, and TPAs. A 2024 survey by the Healthcare Financial Management Association (HFMA) found the top stressors for revenue cycle departments are payer challenges, prior authorization, and workforce issues — costs, shortages, and retention. Complex claims sit at the intersection of all three. 

The industry is responding to that pressure. The healthcare RCM outsourcing market stood at $65.49 billion in 2025 and is projected to reach $117.5 billion by 2030 — a sign that more hospitals are looking outside their own walls for help. Here’s what to look for.  The question is no longer whether to outsource, but rather how to choose the right partner. 

Technology Built for Complexity 

Insurance discovery has surfaced a core differentiator. For motor vehicle and workers' comp claims, identifying the right payer is often the hardest part of the job. Manually tracking this information slows providers down and increases risk of billing errors that lead to compliance problems. Look for a vendor whose platform can identify non-health coverage quickly and consistently— not just through patient calls and letters. 

Beyond discovery, ask how a vendor handles regulatory complexity. Workers' comp involves jurisdiction-specific billing rules, fee schedules, and lien filing requirements that vary by state. A platform that handles these rules systematically will produce better results and fewer missed filings. 

Automation should handle the routine work: routing claims, coordinating billing , sending deadline alerts, and triggering filings. Ask what percentage of claims run through automated workflows and how that impacts days-to-pay.  

As for AI: new tools like predictive triage, automatic extraction of injury and carrier details using Natural Language Processing (NLP), and denial-pattern recognition are useful, but only alongside human expertise. Complex claims will always require clinical, legal, and payer knowledge that automation cannot replace. 

KPIs That Tell the Full Story 

Performance conversations shouldn't stop at collection rate. The following four metrics together give a more complete picture: 

1. Success Rate (% of accounts closed with payment) confirms a vendor converts viable claims into cash, not just works volume.  

2. Reimbursement Rate (total payments / total charges on paid claims) measures yield per account — a high closure rate paired with a low reimbursement rate signals underperformance in billing or negotiation. 

3. New Insurance Identified is often the most telling differentiator. When a vendor surfaces coverage the hospital's own team would have missed, that's net-new revenue tied directly to data depth and discovery capability. 

4. Days to Pay directly affects cash flow. Most hospitals are operating at roughly 1% average margin , making reimbursement speed a first-tier metric. Well-performing vendors in this space average roughly 45 days on MVA claims, under 60 days for workers' comp, and under 10 days for VA.  

When evaluating a new vendor, ask them to benchmark these four KPIs against their full client base, not just your account. 

Verifying What Vendors Promise 

Aggressive pricing can be a signal of a lot of things, and none of them are good. If a proposal is dramatically below market, ask for references who can speak to those specific claims, not just general satisfaction. 

A few operational questions worth asking in any formal evaluation: Is insurance capture driven by technology or by patient calls and letters? Is billing coordination codified into the platform or managed at staff discretion? Does the vendor provide advance notice for timely filing deadlines? Have they been independently assessed through KLAS or a comparable review? 

Process transparency separates vendors that perform consistently from those that perform well only under ideal conditions. In a claim category with real legal exposure and real revenue upside, that difference compounds over time. 

The Right Partner Makes All the Difference. 

The margin pressure hospitals face today makes every recoverable dollar count. Workers' comp, MVA, and VA claims are a smaller claim set with an outsized revenue opportunity — but only when they're managed with the right partner, the right technology, and the right performance expectations in place.  

Revecore's whitepaper, How to Navigate the Maze of Complex Claims, walks through how to assess your current situation and what a stronger path forward looks like.