No Result
View All Result
SUBSCRIBE | NO FEES, NO PAYWALLS
MANAGE MY SUBSCRIPTION
NEWSLETTER
Corporate Compliance Insights
  • Home
  • About
    • About CCI
    • Writing for CCI
    • NEW: CCI Press – Book Publishing
    • Advertise With Us
  • Explore Topics
    • See All Articles
    • Compliance
    • Ethics
    • Risk
    • FCPA
    • Governance
    • Fraud
    • Internal Audit
    • HR Compliance
    • Cybersecurity
    • Data Privacy
    • Financial Services
    • Well-Being at Work
    • Leadership and Career
    • Opinion
  • Vendor News
  • Career Connection
  • Events
    • Calendar
    • Submit an Event
  • Library
    • Whitepapers & Reports
    • eBooks
    • CCI Press & Compliance Bookshelf
  • Podcasts
  • Videos
  • Subscribe
  • Home
  • About
    • About CCI
    • Writing for CCI
    • NEW: CCI Press – Book Publishing
    • Advertise With Us
  • Explore Topics
    • See All Articles
    • Compliance
    • Ethics
    • Risk
    • FCPA
    • Governance
    • Fraud
    • Internal Audit
    • HR Compliance
    • Cybersecurity
    • Data Privacy
    • Financial Services
    • Well-Being at Work
    • Leadership and Career
    • Opinion
  • Vendor News
  • Career Connection
  • Events
    • Calendar
    • Submit an Event
  • Library
    • Whitepapers & Reports
    • eBooks
    • CCI Press & Compliance Bookshelf
  • Podcasts
  • Videos
  • Subscribe
No Result
View All Result
Corporate Compliance Insights
Home Compliance

COVID-Era Data Challenges Can Tip Payers Into Crisis-Management Mode

The pandemic puts pressure on an already strained system of managing manual reviews

by Maria Turner and Erica Nelson
April 1, 2021
in Compliance, Featured
An empty hospital hallway containing a gurney and a doctor in the distance.

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 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.

The Many Challenges of Keeping Health Care Data Up to Date

Provider data includes demographic information such as address, phone number, specialties, office hours and new patient acceptance. It also includes configured provider payment terms like network participation, timely filing requirements, affiliations, discounts/sequestration, uniform rate increases and payment rates and terms. Maintaining the integrity of data significantly impacts both providers and members, including their satisfaction. COVID-19 updates have complicated the management of provider data due to the focus on expedited credentialing of roster additions, as well as the ability for providers to work across state lines.

Organizing provider information, confirming accuracy and maintaining rosters for ever-changing provider groups requires high-touch and consistent communication across multiple parties, both internal and external. Based on research conducted by LexisNexis linked above, an estimated 2 to 2.5 percent of provider demographic data changes monthly, not including other attributes, such as credentialing or affiliations.

Provider data management (PDM) is a highly manual and repetitive process that involves thousands of providers and piecing together the health plan’s network across multiple payer systems. The latter includes provider data management, credentialing, adjudication and the provider directory. As long as PDM continues to be managed through manual processes, exposure to the time-consuming and error-prone process will continue.

Payers’ outdated and inefficient systems rely on a fragile ecosystem of inputs: provider contacts, ever-changing provider alliances, frequently updated physician rosters and regularly revised credentialing data, on top of standard coding logic, payment policy updates and changes in member benefits. When membership shifts geographies or when behaviors shift (like in a pandemic), payers are exposed to changes in their provider networks, causing beyond-normal influxes in PDM updates, whether it be the addition of new providers or changes to billing or rendering information for existing providers. Provider claims that do not mirror the payer’s provider setup typically pend until either the provider onboarding/updating process is complete or the claim is manually reviewed for payment.

Reducing Sanctions Is Critical for Payers

Payers have a responsibility to reimburse claims within the prompt-payment time frames and any delay in reimbursing the provider results in owed interest. Incorrectly paid or denied claims result in sanctions on top of any owed interest. Additionally, sanctions may be levied when incorrect provider information is notated in the provider directory, such as participation, location, specialty or new patient acceptance. The sanctions (commonly referred to “penalties and interest” or “P&I”) have historically amounted to meaningful sums for payers. In many states, delays due to failure to submit accurate data on time can result in significant penalties.

Impact of COVID-19

While most states enabled payers to extend their timely filing deadlines during the pandemic period, health plans continue to be faced with constant updates to provider data. Provider groups are pressured to react to the needs in their local market. Front-line providers are facing urgency and increasing pressure on payers to reimburse promptly, or even ahead of schedule, to ensure their practices have a consistent cash flow during social distancing orders. Providers continue to incentivize staff by offering hazard pay to their health care professionals under these higher risk conditions while looking for ways to accelerate payments from payers.

In order to ensure member access to care, Centers for Medicaid and Medicare Services and state regulators were updating benefits and coding requirements multiple times a week. While this has slowed since the early onset of the pandemic, benefits have been expanded to allow certain provider specialties and places of service the ability to render specific services. New physician affiliations are enabling health care professionals to quickly meet local demands. These changes mean that payer configuration teams must react, update information and, in some cases, create novel payment structures that will exist only during the pandemic.

Pre-pandemic, an estimated 20 to 60 percent of provider online directories were inaccurate. For technology-enabled members, this could mean the difference between spending a few minutes to set up an appointment and spending an afternoon trying to access an available participating provider. During COVID-19, payers don’t want to be a hurdle in the delivery of care by either inadvertently sending a member to an out-of-network provider who is listed in the directory (resulting in higher member cost-sharing) or sending a member to an in-network provider that’s incorrectly configured in the adjudication system (resulting in payment delays, inaccurate payments, higher appeals volumes and increased administrative burden, among other issues).

Automation Has the Potential to Mitigate Payment Window Violations

In an ideal world with technology-driven automation, payers would make provider data changes and process claims without human intervention. During this pandemic period, health payer teams that typically manage provider data are likely working from home. Household challenges, connection issues and meeting distractions pose greater risk of manual error and reduced turnaround times, making the estimated 20 to 40 minutes required (according to LexisNexis) to update a single provider significantly even more difficult.

PDM for most payers requires repetition and consistent follow-up on validation. With interruptions, videoconferencing and the constant flow of emails, PDM productivity has room for significant enhancement. To increase processing efficiency and accuracy, the PDM workflow has the potential to be automated by utilizing digital technology solutions such as optical character recognition and robotic process automation.

Engaging the digital workforce to perform the routine and repeatable process quickly and efficiently allows time for the human workforce to coordinate with the provider network, significantly improving overall health plan effectiveness while also limiting errors.

In Summary

Payers spend millions annually in third-party fees to support the maintenance and ongoing audit of provider data. According to the CAHQ, commercial insurers alone invest over $2.1 billion annually to manage their provider data, which could be significantly reduced with better integration of an in-house digital workforce.

While the providers’ urgent need for quick, appropriate reimbursement is rising, the payers’ timeliness and accuracy is at risk. Whether claims are routine or related to COVID-19, payers need to continue to automate.


Tags: COVID-19Data GovernanceHealth Care
Previous Post

Prepare For Impact

Next Post

It’s Time for a National Privacy Law in the U.S.

Maria Turner and Erica Nelson

Maria Turner and Erica Nelson

Maria Turner is a Managing Director at global consultancy AArete, where she leads the Healthcare Payment Intelligence practice.
Erica Nelson is a Director in the practice.

Related Posts

surgery

Healthcare Price Transparency and Its Market Impact: Where Are We Now and What’s Next?

by Christina Steiner
January 18, 2023

Calls for shedding light on price variability, coupled with an industry that is increasingly consumer-focused, is driving greater examination of...

uvalde crosses

Will 2023 Bring More ‘Permacrisis’ Culture?

by Lisa Schor Babin
January 4, 2023

While 2022 had no shortage of chaotic events, ethics columnist Lisa Schor Babin shares her hopes for 2023 — and...

minidata_b

Honey, I Shrunk the Data: How to Keep Customer Info on a Need-to-Know Basis

by Parker Poe
November 30, 2022

It may be tempting to hoard the data you have gathered on your customers, but an increasing number of regulations...

Creating Effective Compliance Training

Creating Effective Compliance Training

by Aarti Maharaj
November 7, 2022

Build and sustain an effective compliance and ethics training program. Need some guidance on developing and managing your organization’s compliance...

Next Post
American flag flying outside U.S. capitol building

It's Time for a National Privacy Law in the U.S.

Compliance Job Interview Q&A

Jump to a Topic

AML Anti-Bribery Anti-Corruption Artificial Intelligence (AI) Automation Banking Board of Directors Board Risk Oversight Business Continuity Planning California Consumer Privacy Act (CCPA) Code of Conduct Communications Management Corporate Culture COVID-19 Cryptocurrency Culture of Ethics Cybercrime Cyber Risk Data Analytics Data Breach Data Governance DOJ Download Due Diligence Enterprise Risk Management (ERM) ESG FCPA Enforcement Actions Financial Crime Financial Crimes Enforcement Network (FinCEN) GDPR HIPAA Know Your Customer (KYC) Machine Learning Monitoring RegTech Reputation Risk Risk Assessment SEC Social Media Risk Supply Chain Technology Third Party Risk Management Tone at the Top Training Whistleblowing
No Result
View All Result

Privacy Policy

Founded in 2010, CCI is the web’s premier global independent news source for compliance, ethics, risk and information security. 

Got a news tip? Get in touch. Want a weekly round-up in your inbox? Sign up for free. No subscription fees, no paywalls. 

Follow Us

Browse Topics:

  • CCI Press
  • Compliance
  • Compliance Podcasts
  • Cybersecurity
  • Data Privacy
  • eBooks Published by CCI
  • Ethics
  • FCPA
  • Featured
  • Financial Services
  • Fraud
  • Governance
  • GRC Vendor News
  • HR Compliance
  • Internal Audit
  • Leadership and Career
  • On Demand Webinars
  • Opinion
  • Resource Library
  • Risk
  • Uncategorized
  • Videos
  • Webinars
  • Well-Being
  • Whitepapers

© 2022 Corporate Compliance Insights

No Result
View All Result
  • Home
  • About
    • About CCI
    • Writing for CCI
    • NEW: CCI Press – Book Publishing
    • Advertise With Us
  • Explore Topics
    • See All Articles
    • Compliance
    • Ethics
    • Risk
    • FCPA
    • Governance
    • Fraud
    • Internal Audit
    • HR Compliance
    • Cybersecurity
    • Data Privacy
    • Financial Services
    • Well-Being at Work
    • Leadership and Career
    • Opinion
  • Vendor News
  • Career Connection
  • Events
    • Calendar
    • Submit an Event
  • Library
    • Whitepapers & Reports
    • eBooks
    • CCI Press & Compliance Bookshelf
  • Podcasts
  • Videos
  • Subscribe

© 2022 Corporate Compliance Insights

Welcome to CCI. This site uses cookies. Please click OK to accept. Privacy Policy
Cookie settingsACCEPT
Manage consent

Privacy Overview

This website uses cookies to improve your experience while you navigate through the website. Out of these, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. We also use third-party cookies that help us analyze and understand how you use this website. These cookies will be stored in your browser only with your consent. You also have the option to opt-out of these cookies. But opting out of some of these cookies may affect your browsing experience.
Necessary
Always Enabled
Necessary cookies are absolutely essential for the website to function properly. These cookies ensure basic functionalities and security features of the website, anonymously.
CookieDurationDescription
cookielawinfo-checbox-analytics11 monthsThis cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Analytics".
cookielawinfo-checbox-functional11 monthsThe cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Functional".
cookielawinfo-checbox-others11 monthsThis cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Other.
cookielawinfo-checkbox-necessary11 monthsThis cookie is set by GDPR Cookie Consent plugin. The cookies is used to store the user consent for the cookies in the category "Necessary".
cookielawinfo-checkbox-performance11 monthsThis cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Performance".
viewed_cookie_policy11 monthsThe cookie is set by the GDPR Cookie Consent plugin and is used to store whether or not user has consented to the use of cookies. It does not store any personal data.
Functional
Functional cookies help to perform certain functionalities like sharing the content of the website on social media platforms, collect feedbacks, and other third-party features.
Performance
Performance cookies are used to understand and analyze the key performance indexes of the website which helps in delivering a better user experience for the visitors.
Analytics
Analytical cookies are used to understand how visitors interact with the website. These cookies help provide information on metrics the number of visitors, bounce rate, traffic source, etc.
Advertisement
Advertisement cookies are used to provide visitors with relevant ads and marketing campaigns. These cookies track visitors across websites and collect information to provide customized ads.
Others
Other uncategorized cookies are those that are being analyzed and have not been classified into a category as yet.
SAVE & ACCEPT