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Nathan Golia
Nathan Golia
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More Claims Processed Incorrectly This Year Than Last, AMA Says

In its 2011 National Health Insurer Report Card, the association finds a 2% increase in claims processing inaccuracy. Is this a symptom of an illness IT can cure?

June 14, 2010 was a significant date for me for two reasons: it was my 27th birthday, and my first day on Insurance & Technology. One of the first stories I worked on was the 2010 National Health Insurer Report Card, an annual study put out by the AMA on health insurance billing. That year's version found, according to the AMA, that "one in five" claims is processed inaccurately.

I ended up using the story as a jumping-off point for a Virtual Roundtable on how health insurance claims processing could be improved. Because it was an early story/project I worked on, it stuck with me. And this year, when I saw the 2011 NHIRC had been released, I was naturally curious to find out how much better a job insurance carriers had done this year on processing claims.

Unfortunately, according to the AMA:

The overall rate of inaccurate claims payments increased since last year among leading commercial health insurers, according to American Medical Association’s (AMA) fourth annual National Health Insurer Report Card. Claims-processing errors by health insurance companies waste billions of dollars and frustrate patients and physicians.

According to the AMA’s latest findings, commercial health insurers have an average claims-processing error rate of 19.3 percent, an increase of two percent compared last year.

It doesn't sound so bad — it's still around "one in five" (An AMA spokesperson confirmed that last year's 17.3% figure had been rounded up for the press release, and that this year's statement that 19.3% was 2% higher was correct) — but it's slightly disappointing to see that there wasn't a significant improvement, as there had been in the years before last.

I've written about the importance of data quality and integration between health carriers and providers before. My wife and I recently had a son, and in the first two days after we came home, we received three phone calls confirming and reconfirming our insurance information from the hospital's in-house pediatrician. I don't mind helping people do their job, but it's… harrowing to get a lot of calls from the doctor's office right after having a baby (My wife thought one of the voicemails was from the "bone department" as opposed to the "billing department.") Even though we didn't have any health issues to fear, the amount of calls had us worried that certain things wouldn't be covered.

These "communication" problems — between provider, insurer, and consumer, or some combination of two of the three — can be easily solved by innovation in IT. The sooner latest-generation systems are implemented effectively linking the health insurance companies and providers, the less need there will be for them to call, mail, e-mail, text, post alerts in member portals, or otherwise reach out to their customers about simple clerical issues.

Nathan Golia is senior editor of Insurance & Technology. He joined the publication in 2010 as associate editor and covers all aspects of the nexus between insurance and information technology, including mobility, distribution, core systems, customer interaction, and risk ... View Full Bio

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