Athenahealth’s data only represents a portion of each payer’s provider network, but we required a high volume of claims before reporting on any given payer.
In total, then, the data you’ll see on these pages summarizes claims performance from more than 12,000 providers representing more than 30 million charge lines. Services were billed from 39 states to payers in 45 states.
We took all those numbers and ranked payers based on the following measures — see “What We Measured” for a visual breakdown: (For exact definitions and even more data, please visit www.athenapayerview.com.)
Days in accounts receivable (A/R). How many days did it take a physician to get paid from the date the charge was entered in athenahealth’s system? Why it matters: The faster you get paid, the more the money is worth. What it’s worth: 25 percent of total score.
First pass resolve rate. The percentage of claims that were resolved (either paid or passed on to the patients) the first time they were sent in. Why it matters: This measures how much administrative angst it takes to get paid. What it’s worth: 25 percent of the total score.
Denial rate. The percentage of claims that required back-end work, whether the claim was actually denied or just pending. Why it matters: Whatever the reason for the extra work, it takes you longer to get paid and costs you in administrative time — if anyone on your staff actually bothers to follow up on the payment at all. What it’s worth: 20 percent of the total score.
Percentage of patient liability. How much of patients’ bills are paid directly by patients? Why it matters: Consumer-directed healthcare is a growing trend. But most physician offices aren’t set up to collect in full at the time of service. And, not every payer is set up to give physicians the information they need to do so. What it’s worth: 7.5 percent of the total score.
Claim denial transparency. What percentage of denied claims were paid with just one resubmission? Why it matters: This measures how clearly the payer explains its reason when it denies a claim. What it’s worth: 7.5 percent of the total score.
Percentage of claims requiring medical documentation. This measures the rate at which claims are returned by a payer demanding medical documentation. Why it matters: It’s an expensive process, and demeaning for physicians to have to justify their medical judgment to insurance bureaucrats. What it’s worth: 7.5 percent of the total score.
Rate of noncompliance with the correct coding initiative (CCI). Any physician will tell you that one of the worst things about payers is that each one has its own unique set of rules and coding expectations. We dinged payers when they refused payment on claims because their rules were different than national coding standards. Why it matters: How can any billing office keep track of hundreds of rules from dozens of plans? What it’s worth: 7.5 percent of the total score.We didn’t measure how much payers pay. What we’re getting at here is how hard it is to collect what you are owed.
For data on reimbursement levels, download our 2007 Physicians Practice Fee Schedule Survey Results to get a better sense of what payers should pay — and what you should be charging.
Judging national payers
