Health plans receive 98% of medical claims electronically. They pay only 78% of them by electronic funds transfer (EFT). The rest go out by virtual card or check and many carry manual work for the plan or the provider.

Payers are investing significantly to automate administrative work like this. Claims processing ranks as a top-three IT investment priority for 53% of payers, with spending aimed at people-heavy workflows.

Most health plans have built their payment infrastructure for volume. Whether that infrastructure scales is a separate question. The answer shows up as volume grows, in the day-to-day cost of running payments.

Payment evaluations center on throughput and uptime because both are easy to benchmark. Payers choose technology on total cost of ownership and per-transaction pricing and service levels are easy to compare. None of those numbers says what happens to a plan’s operations after volume doubles.

What they leave out are the exceptions like a returned payment, or one rejected because a provider’s bank account changed. Resolving these exceptions incurs time and attention from the plan’s finance or operations team. This lands in internal budgets, spread across departments and rarely added up, which is why the true cost seldom shows up in a Total Cost of Ownership (TCO) comparison.

Exceptions are a share of payments. If a plan’s exception rate holds steady while volume grows, the number of exceptions grows in parallel and so does the staff time spent working exception queues and reissuing returns. A new provider contract can look fine in its first month, but the true cost shows up months later as headcount.

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