Smithson explains that, of the physician inquiries that Humana receives, nearly 55 percent are answered either through a Web site or a telephone-based interactive voice response system. He says that method tends to be more efficient and accurate than calling a provider rep, and he argues it’s a decent replacement for higher-touch, personal communication models that are difficult for big companies to maintain. “When a call does come to us, we have state-of-the-art tools for getting information from the various legacy systems we have … and bringing it back in an easily read format for the customer service rep. To the extent that a claim is in dispute, we don’t burden the customer service rep with that; we have a separate unit that is dedicated to that function.”
All those ugly, disparate, legacy databases from acquired companies are the bane of many payers. In fact, that may account for the relatively poor performance of Indianapolis-based WellPoint and other rapidly growing national companies. Such companies “have incentives to do well, but they’ve grown through acquisitions,” explains LaFontana. “They just aren’t streamlined yet.” (For our ranking of regional payers, click here. Four distinct national regions are illustrated in the map below.)
Smaller, almost-local plans such as Fallon, Tufts, First Carolina Care, and Pacificare of Arizona did well, too.
Fallon says its smaller size makes it possible to have personal relationships with physicians. “We’ve heard from our providers that our reps are much more visible” than those from other payers, says Lisa Mancini Peari, director of provider relations at Fallon. “They actually educate providers instead of just delivering fruit baskets.”
“I think being small or regional, more focused, gives us an advantage in respect to how we relate to our network. It’s something we are trying to focus on even more over the last year or two,” says Rich Lynch, vice president of provider contracting at Tufts.
The Massachusetts market in general is devoted to payer collaboration. Initiatives such as Healthcare Administrative Solutions (www.hcasma.org) bring together major payers in the region to streamline administrative functions such as credentialing. That can only help the process.
What doesn’t help the process?
A fragmented, uninspired Medicaid system. A few states, such as South Carolina and Ohio, have surprisingly efficient Medicaid programs, but the majority of them are slow and maddeningly inefficient. Medicaid performance probably has more to do with the complexity of its plan design than anything else. If that’s true, improving the system will be more complicated than getting a new claims manager or new software. It’ll take legislative action. The really sad part? Without a fix, more physicians will almost certainly leave the Medicaid program altogether.
Take New York Medicaid, the worst payer in the Northeast. LaFontana says its payment system involves “inconceivable complexity.” For example, New York Medicaid doesn’t accept the standard claim form, the CMS 1500; it has its own “standard” form. And physicians can’t just download that form; the state mails the forms out, sending just as many as each physician used last month. If you see more Medicaid patients this month, too bad. “You literally can’t bill. You run out of paper,” says LaFontana.
Medicaid of Illinois, fifth from the bottom of our Midwest list, “actually stops paying physicians anything once it runs out of budget. It’s getting close to six months every year they are not paying. But they still beat New York’s days in A/R,” observes Delinsky. We wanted to give the New York and Illinois Medicaid systems an opportunity to respond, but officials didn’t answer our queries.
“Why have we allowed the Medicaids to evolve to be 50 totally inefficient, redundant nightmares when the same system created Medicare?” asks LaFontana. Instead of always talking about Medicaid costs, she suggests, legislators should look at fixing some of the administrative waste. Solving such problems might make it possible to provide better care and broader access.
What can you do?
How can you use the PayerView data to improve life at your practice?
Start by acknowledging your own responsibility to develop productive relationships with your payers.
