Percentage of claims requiring medical documentation — Is there anything more irritating than submitting a claim, only to get back a request for medical documentation? Now someone has to go pull a chart, search some journals, make a bajillion copies, and send it all back, probably on paper. Not to mention the implication that the payer is deciding what services the physician ought to be providing. “Medical documentation requirements are becoming more prevalent,” says Suzanne Verden, president of The Verden group, which helps physicians with payer relations. “I see it in surgical practices a lot, especially orthopedics, and especially if the surgeon develops a specialty in some procedure.” She has seen the requests really affect practices. The rationale for including this metric: Annoying and expensive requests for documentation are bad in our world, and we started measuring them this year. The weight we gave this metric: 7.5 percent of the total score.
Percentage of noncompliance with the Correct Coding Initiative (CCI) — One of the worst things about payers is that each one has its own unique set of rules and coding expectations. How can any billing office keep track of hundreds of rules from dozens of plans? So, we dinged payers when they refused payment on claims because their rules were different than national coding standards. The rationale for including this metric: “Instead of having the burden put on providers in having to follow rules from 30 payers, it’s great that this metric puts the pressure back on the payers,” cheers Verden. The weight: 7.5 percent of the total score.
We didn’t measure how much payers pay. Our goal here is to rank payers according to how hard it is to collect what you are owed. After all, if Payer A promises great rates but takes 70 days to get them to you, are they really a better payer than Payer B who pays a little less but gets it to you in 35 days?
Still looking for reimbursement data? No problem. Download our 2006 Physicians Practice Fee Schedule Survey Results to get a better sense of what payers should pay — and what you should be charging.
The lowdown
So, after all that data crunching, what did we see?
First, physicians are getting paid faster. Days in A/R decreased, on average, 5 percent for national payers and 3 percent for regional payers from 2005 to 2006. It now takes just 34.4 days from the time you enter a charge to the time it gets paid. That doesn’t count days added before you submit the charge, if that’s a problem in your office. Of course, three days to payment would be better than 34 days, but it’s nice to see the industry moving in a positive direction.
Here’s more good news: The extent to which payers deviated from national coding standards dropped 25 percent nationally and 20 percent regionally. That makes it easier to code right the first time without machinations for each payer.
Denial rates are also on the decline; around 16 percent fewer claims were denied last year than the year before, though this partially reflects athenahealth’s growing expertise in avoiding denials for its clients. In other words, pretty much everything that’s supposed to be going up is going up, and everything that’s supposed to be going down is going down.
Melissa Lukowski, athenahealth’s director of payor outreach, credits increased transparency for these improvements. “Transparency initiatives adopted by many national and regional payers are bearing fruit,” she tells us. “Payers are investing a great deal of resources in making tools available to providers. They are really heavily documenting, making information available through Web sites, mailing to providers. Outreach and education are going up — it’s playing out in the numbers. The ones that have experienced the best scores are the ones doing the best job at this.”
Bottom line: Payers are doing a better job of explaining what you can do to submit claims correctly in the first place. If your practice isn’t seeing these improvements, it may be that you aren’t taking advantage of what’s available, or your staff still finds the information more opaque than crystal clear.
A final trend: “Consumer-directed healthcare is on the rise, and our data is actually showing that increase as well,” says Lukowski. It’s time to hone your policies and processes for patient collections.
Meet the best
Our national results indicate that, overall, Cigna is the best-performing national payer, upsetting Humana, which took top honors last year. Cigna’s top ranking was thanks largely to its high 96.3 percent first pass resolve rate and low 5.9 percent denial rate.
Bill Fandrich, product executive for all the point-of-service capabilities for providers with Cigna, says he and his colleagues expected a good showing, and says he’s grateful someone is making a public issue of payer-physician relations. “We very much were pleased to see that an organization took the initiative to publish these rankings. When we saw the rankings last year, we were very certain we could improve for this year … and think we can improve even more in the future.”
