Is your practice struggling to monitor payer performance? You may share Barbara Sack's view.
"Some days [monitoring payer performance] seems like the bane of my existence," says Sack, administrator of Midwest Orthopedics in Shawnee Mission, Kan. "It's another reason that it now takes more billing people than clinical people to see a patient, which is a frustration for all of us in healthcare."
When approaching the task of monitoring payers more closely, consider the advice of P. J. Cloud-Moulds, owner of Medical A/R Recovery, and a blogger on PhysiciansPractice.com.
"Just like a doctor might say to a patient, 'this is going to hurt but, in the long run, you are going to feel better,'" Cloud-Moulds says.
Some practices focus too much on payment rates when considering the value of their payer contracts, giving too little consideration to payer performance as defined by payment timeliness and accuracy, administrative hassles, denial rates and reasons, and more. Understanding a payer's performance as a partner in your business requires a complex and nuanced analysis of metrics that haven't always been easy to come by.
Yet for most practices, monitoring payer performance is usually worth the time and effort, even if it requires more staff, experts say.
You can simplify matters by focusing only on your biggest payers: Create a basic spreadsheet with your most important private payers and, within that set, scrutinize only those payments for the services that make up the majority, say 85 percent, of your practice's gross charges. It may be as few as 25 or 30 CPT codes.
Although even that number of codes can be onerous to monitor on a regular, payer-by-payer basis, consider the potential payoff of a careful performance-monitoring program: major commercial health insurers had an average claims-processing error rate of 19.3 percent in 2011, up 2 percent from the previous year, according to an analysis by the AMA.
And in athenahealth's just-released PayerView report, an analysis of payer performance based on real claims data from the national billing and practice management services company, payer performance has been declining as insurers shift resources away from improving their claims-management process and toward meeting new government regulations. Joe Hendrickson, vice president of athenaNet Intelligence, which compiles the annual PayerView data, says that the company's analysts are not expecting payer performance to improve next year. In fact, after several years of steady improvement following the debut of PayerView in 2005, it's possible that payer performance has more or less topped out, Hendrickson suggested.
The latest edition of PayerView, found that payers, overall, are taking longer to pay, that fewer claims are getting paid on their first submission, and that higher percentages of what's owed to practices are being pushed onto secondary insurers and other parties from which the practice must seek payment separately.
In other words, athenahealth found, it's getting harder to get paid.
*How are your payers performing? Find out with our in-depth national and regional data: Blues / Major Payers / Medicaid / Medicare / National Commercial / Midwest / Northeast / South / West. This information is also available at athenahealth.com.