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AMA Ranks Payers' Claims Processes, Which are Often a 'Murky Mess'

Cheryl Clark, for HealthLeaders Media, July 22, 2009

In hopes that it may lead to reduced payment hassles and could save doctors time and money, the American Medical Association yesterday scored seven large health plans plus Medicare in their promptness and accuracy for paying claims.

The survey found a wide variation in practices among the payers, with each using a different set of rules, different timelines, and confusing and inconsistent processes.

The doctors group also listed numerous recommendations for improving the system that would "professionalize transactions, modernize procedures and clarify what is now a real murky mess," said William Dolan, MD, a member of the AMA board of trustees as he released the survey's results.

"Physicians are now bogged down in paperwork," which requires they divert as much as 14% of their gross revenue to assure accurate payments, Dolan said in a Webcast to release the new survey. Ideally, he added, the AMA wants to reduce physician expenditures on such processes to only 1% of their revenue.

"This would reduce angst, and let me tell you there's a lot of it in the healthcare industry, and return the focus to patient care," Dolan said.

Currently, doctors spend a total of three weeks a year, sometimes as much as 35 minutes a day, muddling through, trying to figure out what codes to use and what insurance plans will cover, at a cost of $200 billion a year, he said.

This release of the AMA scorecard is the group's second in a campaign that began last year to put pressure on health plans and Medicare to streamline and standardize their divergent systems into one.

In the report, the AMA compared Aetna, Anthem Blue Cross Blue Shield, Cigna, Coventry, Health Net, Humana, UnitedHealthcare, and Medicare in 18 measures from various points in 2008 and 2009.

Ideally, the AMA wants all claims processes to be simplified so that physicians don't have to work through a confusing array of procedures and rules that take time away from their patients. It also would make it easier for physicians to avoid mistakes when they request reimbursement for care.

"In simplest terms, this campaign would eliminate waste by getting things right the first time," said Dolan, an orthopedic surgeon at the University of Rochester.

Some portion of the solution, the doctors' group said, is mentioned in the so-called Tri-Committee health reform proposal emerging in the House. They hope it will be carried forward in any reconciled legislation that emerges.

Most health plans showed improvement
For physicians, one of the most vexing parts of the claims process is how well insurance plans and Medicare pay the rates as stated in their negotiated contracts. Five of seven health plans significantly improved on this score over 2008 by between 11 and 17 points.

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