Physicians Practice Articles : PayerView: You be the Judge — PayerView Reveals Who Treats Physicians Right

Business Resources
by Category

-- Advertisement --
View a free webinar on Revenue Cycle Management.

-- Advertisement --

White Papers

Revenue Cycle Management A-Z
- Sage

View All

Can the Communications Highway work for You?

Try our "Virtual Buyers Guide!"
-flip through the pages!
-search by keyword!
-download to your desktop!
-forward to a colleague!

< Home < Articles < Article Details

PayerView: You be the Judge — PayerView Reveals Who Treats Physicians Right
By Pamela Moore

Tired of being judged by payers? Here’s your chance to judge them.

For the second year in a row, Physicians Practice has teamed with athenahealth, inc., to produce hard data on how well payers are treating physicians. The result, our annual PayerView^SM report, is within these pages. We name names and give grades so you can make better contracting decisions.

Our goal: to illuminate the dark recesses of the physician payment process, revealing problems in order to fix them, and to share what good payers are doing so the rest of the industry can catch up. While the picture that emerges isn’t entirely encouraging, there is reason to hope for better relations between physicians and payers. That’s because when you start measuring performance, and making the results public, performance tends to improve. Payers start to care more about it.

In other words, PayerView seems to be having the effect we hoped it would: Payers generally are becoming more efficient, and that’s good news for them and you.

Now let’s have a look behind the curtain.

Instead of reporting on anecdotal or slapdash opinions about payers, PayerView is based on actual claims data derived from athenahealth’s athenaNet^® database. Based in Watertown, Mass., athenahealth provides physician billing, practice management, and EMR services via Web-based software to practices all over the country. It has access to oodles of billing and payment information, and with our input, it used data covering all 12 months of 2006 to develop a system to compare payers in terms of how they treat doctors. Physicians Practice has developed a chart that describes the measurements we used to rate payers and the weights we gave each measurement.

To make things fair, we report on only those payers for which athenahealth has data from at least 30,000 charge lines per quarter (for national payers) and 5,000 charge lines per quarter from regional payers. This is an even higher benchmark than we used last year. Also, at least six of athenahealth’s physician-practice clients had to be represented in data on any given payer; that’s because we didn’t want to report trends from just a few practices.

If one of your payers is not on the list, it’s because we didn’t have enough data on that payer to report on it. Still, even this high standard allowed us to capture enough data to report on dozens of payers around the country.

In total, then, the data you’ll see summarizes claims performance from more than 8,500 providers representing more than 28 million charge lines billed from 33 states and submitted to payers in 46 states.

We took all those numbers and ranked payers based on the following measures:

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? The math: Average total outstanding A/R divided by the average daily charge. The rationale for including this metric: The faster you get paid, the more the money is worth. The weight we gave this metric: 25 percent of the total score.

First pass resolve rate — The percentage of claims resolved (either paid or passed on to the patients) the first time they were sent in. This is a slight change from last year, when we measured just first pass pay rate — the percentage of claims actually paid on first submission. But it’s legitimate to count the other sort of resolution as a reasonable outcome as well. The rationale for including this metric: First pass resolve rate characterizes the amount of administrative waste and angst it takes to get paid. The weight we gave this metric: 25 percent of the total score.

Percentage of patient liability — So-called consumer-directed healthcare plans that force more costs onto patients in the form of higher copays and deductibles are all the rage. That may be good for health plans, but it’s generally bad for practices because patients are harder to collect from than insurers. This is a measure of the percentage of billed charges transferred to the patients. The rationale for including this metric: It helps describe how much burden is placed on physicians, who must figure out how much patients owe and collect it. The weight we gave this metric: 7.5 percent of the total score.

Denial rate — The percentage of claims that required back-end work, whether the claim was actually denied or just rendered pending. The rationale for including this metric: When a claim is denied, it takes you longer and costs you more to get paid — if you ever get paid at all. The weight we gave this metric: 20 percent of the total score.

Claim denial transparency — This measures the percentage of denied claims that were then paid with just one resubmission. This is a new measure this year. The rationale for including this metric: To gauge how clear the payer is when they deny a claim. Does the explanation of benefits or a customer service rep on the phone make it easy to understand how to get the claim processed? If so, you’re likely to get paid on the first resubmission. The weight we gave this metric: 7.5 percent of the total score.

1 2 3 4 Next >

Additional Resources

View more articles from the June 2007 issue

View more articles related to Billing & Collections

-- Advertisement --

Need More Help?
Ask an Expert.

What do you think?
Comment now!

In Summary

The second annual PayerView reveals how easy it is to work with individual payers:

Cigna, Aetna, and Medicare did best nationally. The Blues performed well regionally.

Days in A/R dropped, overall, from last year to 34.4 days.

More payers are following the coding rules set by the Correct Coding Initiative.

Consumer-directed initiatives are on the rise, meaning practices need to focus more on patient collections.