If you visit the provider portal of a health insurer’s Web site, you’ll invariably encounter them — photographs of smiling doctors. Trim and plucky, they seem tickled to do business with that particular insurer, which pledges nearby that it’s absolutely committed to making claims processing and reimbursement as easy as possible.
Those smiling “doctors” are models, of course.
So what’s the real world like? Which insurers truly warrant smiles — or frowns?
The fourth annual PayerView has some answers.
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Physician fee schedule survey
Monitor payer contracts
Make your payers pay
PayerView, in short, ranks payers according to their level of hassle-factor: how quickly they pay you, and how much they hogtie you with denials, delays, and red tape. These rankings can help you negotiate contracts with payers — and walk away, if need be. The comparisons also keep the payers on their toes, and even inspire them to vie for a number-one ranking.
The good news is that at a time when reimbursement amounts are declining, PayerView appears to be having the affect we intended when we launched it with athenahealth in 2006. It looks as if payers are, in fact, working harder to work with you better. (Curious about changes from previous years’ data? Check out the 2007 and 2008 PayerView results.)
Let’s have a look at the numbers:
Aside from dismal state Medicaid programs, payers are generally doing more to earn your trust. For athenahealth clients, days in accounts receivable and denials dropped in 2008 despite obstacles posed by the National Provider Identifier, or NPI, taking effect last year. “I didn’t expect as great of a performance as we got,” says Melissa Lukowski, athenahealth’s director of payer outreach. “With everything that could have gone wrong with NPI, its impact was minor.”
(*See our complete payer rankings broken out by payer and region.)
Four forces
The improving numbers stem from four positive forces. One is the corrective spotlight of PayerView. Also, athenahealth’s work with payers to solve claims-processing bottlenecks is improving things for its clients, whose experiences are reflected in the numbers. Another force is the sheer onward movement toward computer automation. “More doctors are submitting claims electronically, and payers are implementing real-time adjudication,” says Todd Welter, a management consultant in Denver who specializes in payer contracting.
The fourth positive factor was a massive class-action lawsuit brought by organized medicine in a Miami federal court against the nation’s leading health insurers almost 10 years ago. Its goal was to make them repent of slow-paying, automatic downcoding, improper code bundling, and other nasty tricks. The plaintiffs described themselves as “hundreds of thousands of doctors being systematically cheated out of small amounts of money.”
Six defendants eventually settled, vowing to make their claims processing faster and fairer (and coughing up hundreds of millions of dollars in restitution as well). Not surprisingly, the three highest-ranking national commercial insurers in PayerView — Humana, Aetna, and Cigna — were among the first to settle.
“Slow pay hasn’t disappeared, but most payers have sped up,” says Deborah Winegard, an Atlanta attorney who has represented organized medicine in enforcing compliance with the settlements. “The settlements fundamentally changed the dialogue between doctors and payers, but that doesn’t mean all the problems have gone away.”
Meanwhile, patient responsibility rates have yet to become the bogey man that some predicted. Placing more of the financial burden directly on patients, who are harder to collect from than insurers, has long been expected to strain physicians further, but so-called consumer-driven healthcare seems to be growing more slowly than many expected. “Some trade publications have predicted 20 to 30 percent growth in consumer-driven healthcare plans,” Lukowski says. “But we have actual data, and it shows the growth is not that aggressive.”
Yes, there are still problems. And the current recession could sour things even more. However, the view from PayerView represents some precious good news.
What PayerView examines
The claims-processing data analyzed by PayerView comes from doctors who rely on athenahealth for their billing. So the information doesn’t represent a given payer’s entire network. Still, the PayerView sample size is large enough to be instructive: almost 19,000 providers in 40 states who billed 172 payers in 47 states during 2008. Their total claims represent almost 42 million charge lines. Delving into this data, PayerView compiles scores based on the measurements described in this table.
None of these metrics involve how much or little insurers are paying you. For that information, download our 2008 Physicians Practice Fee Schedule Survey results.
National payers
According to PayerView, Humana ranked as the easiest national payer to deal with in 2008. Except for requiring documentation on more pended claims, the company improved in every performance metric, and led the pack with the fewest days in A/R (26.65) and denial rate (5.3 percent). Lukowski says Humana’s roll-out of real-time adjudication (RTA) with athenahealth clients — which tells the doctor’s front desk at the time of service what Humana will pay on a claim, and what the patient owes — was a big reason why its days in A/R decreased by 3.45. (Disclosure: Physicians Practice publishes a provider newsletter for Humana.)
Mark Smithson, Humana’s vice president of provider process and network operations, says promoting RTA works for his company as well as the practice. “The faster we turn claims around, the less work we have on our end,” says Smithson.
