What happens when a backlog of COVID-related claims meets a mountain of faulty, false or missing data? Payers don’t pay on time — or at all. Here’s how the pandemic is impacting the health care industry’s chronic struggle with manual reviews.
Most states can levy huge, frequently multimillion-dollar, sanctions on health care payers that do not reimburse provider claims within the prompt-payment window. Although payers regularly struggle with this issue, COVID-19 has caused heightened sensitivity. As more and more claims fall out of the auto-adjudication process and into manual review work queues, the the backlog of pending claims and the potential for inaccurate and/or late payments keeps increasing.
Low-quality provider information has long afflicted the health care industry and is one of the main contributors of claims dropping to manual review. Pre-pandemic, an average of 20 to 30 percent of claims fell out of the auto-adjudication process, resulting in the need for manual review. An estimated 25 percent of claims falling to manual review, according to research conducted by LexisNexis, are the result of issues related to provider data quality, including incorrect, inconsistent, incomplete, duplicate or missing provider information.
