Fandrich credits a back-to-basics approach and better communication with providers. Cigna sent its many Six Sigma black belts out to fix basic business processes. For example, the payer industry traditionally measures payment accuracy based on whether its payments matched the contract terms in its own system. Physicians, though, judge accuracy based on whether the payments meet their understanding of the contract. Cigna is now at pains to make sure its interpretation matches physicians’ interpretations, Fandrich says.
Cigna also measures how many claims it can handle without a manual intervention — and it doesn’t just count claims that make it through the submission process. Company officials want to know, out of all the claims providers send, how many it handles smoothly. If the electronic data interchange channel rejects a claim before it enters Cigna’s system because the claim is missing information or is coded incorrectly, Cigna still counts that as a manual rejection, and works to avoid it. “We started counting them all. The rejection still causes a lot of redundancy and frustration in the environment,” regardless of the reason, Fandrich says. “We took the holistic view.”
Cigna also created “dedicated provider service liaisons to respond to physician concerns and anticipate where we might have issues and prevent them,” Fandrich reports. “A provider now has a single point of contact they can call and communicate issues. There is a name they can use. Before, we had a call center and a service team but they might not be dedicated to that provider. Now they have intimate knowledge of this provider’s environment.”
Cigna thinks providers are getting more and more interested in payer performance and wants to stay ahead of the curve. It seems the company is doing just that.
Yet while Cigna outperformed its peers, it wasn’t by much.
Aetna, which placed second, thinks the key to better performance is transparency and communication. “We try to make our rules accessible and make the Web site easy to use, so literally a physician or someone in the physician’s office can access that data very quickly. Accessibility and ease of use are concepts we try to push,” explains Alan Karp, vice president of healthcare delivery for Aetna. “We want to get away from the black box mentality. We try to communicate as often as we can with our physician partners.”
The Blues plans also did well in their respective regions. “I am not surprised to see Blue Cross Blue Shield plans at the top or near the top of the list in each region,” says Verden. “They seem to have a good IT structure and to educate providers really well.”
Low-ranked national payers, United and WellPoint, are in acquisition mode, notes Lukowski. “Performance does seem to be impacted by acquisition.” It makes sense — consolidating information systems can cause payment mishaps.
To get a more complete assessment of payer performance nationwide, PayerView ranks payers by region as well. This allows you to check how payers are performing in your specific area of the country.
Medicare muddle
Medicare performed well nationally, ranking third overall. Say what you will about how much Medicare pays, but having public, standard rules for coding, coverage, and prompt payment goes a long way toward making it easy to work with.
What’s surprising is the variation among regional Medicare carriers. Medicare is supposed to be a national payer, after all, but Medicare in Illinois pays in 29 days while Medicare in New York takes 51 days. In fact, not all Medicare carriers are even following CCI edits. New Jersey ignores them 2 percent of the time.
The variation “was actually news to CMS as well,” Lukowski reports. “The general understanding is that every carrier should be applying the CCI standards, and that’s not actually playing out. There is no real explanation for why the variation is there.”
Medicaid performance is a hodgepodge — just as you’d expect for something run by 50 different states — except that all Medicaid programs have higher days-in-A/R and more denials than most commercial plans. Still, working with the better-performing Medicaid programs, like those in Ohio and South Carolina, isn’t that bad. It may be time to push other states to follow the example of strong performers; there would be less paper pushing and more money for care.
Bottom line
