Health insurers are paying physicians 5% faster and denying 9% fewer medical claims than last year, but some payers still have a ways to go, most notably state Medicaid programs, according to athenahealth's fourth annual PayerView Rankings.
The Internet-based provider of business services to physician practices evaluated 172 national, regional, and government payers in 40 states, which was the largest data set to date. The company used performance data from more than 18,000 medical providers and $7 billion in charges billed in 2008.
Athenahealth found that many payers are collaborating more with physicians to automate various claims and billing work, while reducing administrative costs and streamlining claims processing. That allows providers to focus more on delivery of care. Jeremy Delinsky, vice president of athenaNet Intelligence for athenahealth in Watertown, MA, says health insurers should focus on reducing administrative waste from the healthcare system.
He adds it's up to stakeholders to remove inefficiencies or someone else—such as the federal government through the proposed public insurance option—will.
Through its research, athenahealth found these trouble spots often lead to delayed physician payments:
- Health insurers' varied policies and procedures for claims submissions and payment that can cause confusion in physician offices.
- Real-time claim adjudication that don't help practices integrate the technology into their workflow, but is really a euphemism for additional work for practices, such as needing to rekey information onto the payer's Web site.
- Insufficient resources for providers, including inadequate call center staff, which makes it difficult for offices to research and/or follow claims, leading to misinformation and additional phone calls to resolve the issues; outdated and difficult to find provider manuals and other documentation; and incomplete information that doesn't provide enough insight to help offices learn where they may have made mistakes in the process.
Humana is tops
Humana topped athenahealth's rankings for the second time in four years and garnered the top spot in fewest days in accounts receivable for national payers. Humana edged out Aetna and Cigna, the highest rated national payers in the 2007 and 2006 athenahealth results respectably.
Mark Smithson, vice president of provider process and network operations at Humana in Louisville, KY, points to two reasons for the high marks: real-time claim adjudication and electronic remittance devices. Smithson says many health insurers say they have real-time claim adjudication, but still require physician offices to log onto the payers' sites and rekey in the information. This merely adds work to physicians' offices. Instead, insurers should integrate the claim adjudication process into the physician offices' practice management system, he says.
"We don't change dramatically how they put their charges in," he says. "Not only does it help at the patient collection window; it also speeds up the entire process."
Not that the changes are seamless. Smithson says the health plan and office must work to have the process complement the workflow, but realize the changes will affect workflow. "What this does do is streamline all that so the person is no longer in the back office, but in the front office at the patient window so it does somewhat disrupt their workflow," he says.
For instance, one practice has color-coded Humana patient charts so the office employees know that it has a different workflow than others. What's important is to educate the physicians' offices from the start so they know what changes are needed. "The better the communications upfront the more smooth the whole transition is going to run," he says.
Smithson says Humana's mindset is that it would rather pay pennies to process the claims through streamlined processes and avoid backend phone calls. Smithson says each phone call avoided saves the company $7.
Medicaid is a problem
While many of the national and regional health plans performed well, state Medicaid programs were at the other end of the spectrum. Medicaid had a twice longer days in accounts receivable (DAR) than other groups and denied more than one in every five claims.
The New York Medicaid program ranked worst for DAR and first-pass resolve, which athenahealth suggested was because of:
- Complex authorization requirements
- Use of proprietary claim forms for paper submission
- Lack of acknowledgment from Medicaid-NY for claims submitted
- Use of identical remittance codes to indicate both denied and pended claim scenarios
- Onerous enrollment processes
These results are quite different from Medicare, which received much higher marks in the rankings. Diving deeper into the findings, athenahealth found that Medicaid managed care programs, which are operated by private insurers, performed much better than state Medicaid programs.
One problem is that states faced with limited budgets often make cuts to Medicaid programs and/or stop paying claims, he says.
"That is essentially like taking an interest-free loan on the backs of medical providers. There has to be a better way to fund the system than to have providers essentially treat patients for free upward of 90 days. That just doesn't feel like the states have responsibly managed their budgets if that's happening. You can understand why the provider wouldn't want to participate in the program," says Delinsky.
Delinsky says athenahealth's rankings look at administrative ease and efficiency, but the company would like to expand its program to include other areas to make them more meaningful for providers. "I think you can probably make some correlation about administration efficiency if you had more data publicly about these companies, but it doesn't get into comparative payments yet. That is something we're likely to do in coming years," he says.