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AMA: 1 in 5 Insurance Claims Bungled

Margaret Dick Tocknell, for HealthLeaders Media, June 21, 2011

It looks like health plans and physicians are still having trouble communicating about medical claims. Commercial health insurers bungled an average 19% of claims in 2011 – meaning they were improperly denied or paid the wrong amount. That's an increase of two percent – or about 3.6 million additional claims errors ? compared to 2010, according to the 2011 National Health Insurer Report Card from the American Medical Association.

The AMA says that the 19% error rate translates to an estimated $17 billion in annual waste.

The report card, which was released during the AMA's annual meeting in Chicago, looks at the timeliness and accuracy of claims processing at Medicare and seven of the largest health insurers: Aetna, Anthem Blue Cross and Blue Shield, CIGNA, Humana, The Regency Group (Blue Cross Blue Shield-affiliated health care plans in Oregon, Washington, Utah and Idaho), UnitedHealth Group, and Health Care Service Corp. (parent of Blues plans in Illinois, New Mexico, Oklahoma and Texas).

The study analyzed a random sample of 2.4 million electronic claims for about 4 million medical services submitted in February and March of 2011. The claims were collected from 400 physician practices covering 16,000 physicians in 80 medical specialties in 42 states.

In terms of accuracy, UnitedHealth scored the best rating -- 90% -- up from 86% the previous year. It was also the only health plan to improve its score from 2010. With the exception of Anthem, the remaining plans plus Medicare either remained the same or posted negligible declines in their accuracy rates. Anthem's accuracy rate dropped to 61% from 74% in 2010.

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