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.
For example, Cigna improved in this category from 66% to 83% while Humana improved from 84% to 93%. Coventry, however, went from 86.7% to 71.9% and HealthNet did not disclose the information. Medicare payments were the most closely aligned, with about 97.5% accuracy.
Another issue is the wide variation in how health payers deny claims.
"The inconsistency found among health insurers in 2008 continues to be demonstrated in 2009," the AMA said in a statement. "The wide variation in how often health insurers deny claims, and the reasons used to explain the denials, indicates a serious lack of standardization in the health insurance industry."
The survey was compiled through a sampling of the National Healthcare Exchange Services (NHES) database, which includes more than 2.5 million services billed within 1.6 million claims from physicians in 62 specialties and 200 practices in 29 states.
Compounding the problem with denials is that in many cases, the claims were correctly denied because the patient did not have coverage for a specific service in their plan. Eligibility continues to be the largest reason for denial, the survey results indicated.
"We need to improve the mechanics of answering the most basic of questions: Is the patient covered by a health insurance plan and (which) is it?" said Mark Rieger, NHES chief executive officer.
All of the records surveyed were taken from practices with electronic records systems. Rieger said the scores would probably be much lower if records from practices that had not yet adopted electronic databases had been reviewed.
Other process measures evaluated in the report card include whether physicians can accurately tell how long each plan will take to reimburse a claim or the amount of time before the physician receives the first check, and whether the plan clearly discloses pre-authorization policies and procedures online.
Another variable scored is how often health plans "claim edit," a process by which plans try to bundle separate billings under one category, which may reduce the amount the physician receives despite the number of times the patient was seen or the amount of care given.
At least four plans and Medicare were asked for comment on the report card.
"We value the AMA's report card on our performance as a way to help us improve how we work with the physician community…and have discussed the report card with the AMA throughout the year to identify improvements," Cigna spokeswoman Amy Turkington replied in an e-mail.
Such changes include revising its communication procedures, "so the information we already provide through our paper explanation of payment will be available on the electronic remittance as well," she wrote.