Update on Health Insurance Claims Processing Costs

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Paper versus Electronic

[By Matias Klein]

[Senior VP Technology Portico Systems Integrated Provider Management Solutions]

The average cost of processing a single, clean, paper-based or electronic claim can range from 85 cents to $1.58.

However, according to AHIP, nearly half of all claims (48 percent) were pended due to the submission of duplicate claims (35 percent), lack of complete information or other information needed to justify the claim (12 percent), or invalid codes (1 percent).

The manual adjudication of these duplicate or incorrect claim submissions increases the cost of administration to $2.05. The $2.05 scenario is a best case calculation. In our actual field experience the cost can be as high as $10.00 per claim.

Payment Delays

In addition to the increased administrative cost, one must not forget about the delayed payment to the provider. As stated by AHIP, a duplicate claim can take 9 days to remediate and missing information on a claim can take up to 11 days. This kind of delay damages the relationship between the provider and the health plan, which in terms of costs is priceless.

Enter ID Management

To solve this problem, some healthcare organizations are implementing Master Identity Management (IDM)—a valuable approach to creating an enterprise “source of truth” for provider identity information. But when it comes to payment integrity and claims processing, IDM without a Provider Information Management (PIM) system doesn’t work. Provider relationship and contract data are far too complex, and both types of data are needed to supplement provider identity data in support of claims administration.

Provider Information Management

When IDM is fully integrated with PIM, payers can successfully establish a single, accurate and effective source of truth. An integrated approach also:

  • Ensures quality – by standardizing, cleansing, cross-referencing and consolidating relevant data, while removing duplicate entries.
  • Mitigates risk – reducing the downstream impact of inaccurate data on all claims processing, contracting, credentialing, provider directory and connected systems.
  • Saves millions of dollars – by reducing duplicate entries by even a fraction of a percent, thus ensuring that claims are being processed in an efficient and effective manner.


IDM plays a pivotal role in the future of healthcare. As new, collaborative and accountable care delivery models evolve, reliable provider identity management is absolutely critical. Combining IDM with PIM gives payers the most powerful solution for assuring payment integrity while improving provider identity and duplication management.


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Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com


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5 Responses

  1. Why healthcare overpays for technology

    Did you know that healthcare organizations pay an average of 17 percent more for information technology than other industries, according to a report authored by Net(net), a consulting firm specializing in IT optimization, which sampled 30 total industries?


    Why? Because doctor’s have mud for brains – and pay, pay and pay!



  2. Health insurance Premium Costs

    The average family’s health insurance now costs about $16,000, and workers pay more than a quarter of that, according to a new survey.




  3. Spending Inefficiencies in Healthcare Professional’s Workplaces

    According to the Coupa Software 2013 Healthcare Survey, 78 percent of healthcare professionals identified spending inefficiencies in their workplace.

    Top concerns included:

    • Wasteful spending (35%)
    • Insurance mandated process work (32%)
    • Late physicians (25%)
    • Useless tests (22%)

    Source: Coupa Software


  4. Out-of-Network Rates Drive Unexpected Medical Costs

    When out-of-network physicians perform hospital procedures, hefty charges can be added to medical bills. Insurers often pay the full amount or large portions, which provides an incentive for doctors to include out-of-network colleagues.


    Source: The New York Times [9/20/14]


  5. Blue Cross Blue Shield Plan Operational Administrative Cost Trends

    Sherlock Company recently released the 2015 Blue Cross Blue Shield Plan edition of the Sherlock Expense Evaluation Report. Here are some key findings from the analysis:

    • Operational administrative expenses for Blue Cross Blue Shield Plans increased 1.1% per member in 2014.
    • Account and Membership Administration costs increased by 3%, the lowest rate increase since 2011.
    • The median total costs before Miscellaneous Business Taxes was $33.37 per member per month.
    • Miscellaneous Business Taxes increased by 369.1% because of Affordable Care Act taxes and fees.
    • When ACA taxes and fees are included, the total administrative costs per member increased by 18.4%.
    • The growth in Sales and Marketing and Medical and Provider Management declined to 2.0% and 1.6%.

    Source: Sherlock Company, July 6, 2015


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