Who are the best and worst payers for physicians in America?
According to athenahealth, Inc., Humana, Inc. topped the list of 138 payers owing to the company’s quick turnaround of claims and transparency in its reasons for denying claims. The top payers include:
- Humana
- Medical Mutual of Ohio
- HealthPartners
- BCBS Massachusetts
- UnitedHealthcare
- Medicare Part B in Missouri
- Aetna & Aetna-US Healthcare
- BCBS in the District of Columbia
- MVP Health Plan of New York
- Medicare Part B in Connecticut
The worst? State Medicaid programs in California, Oklahoma, Pennsylvania, New Jersey and Texas.
(To view the entire list, click here)
Sixth Annual Ranking of the Best and Worst
On June 26, 2013, PayerView 2013 was released by athenahealth and published in the July/August issue of Physicians Practice. It is the sixth annual ranking of the best and worst health insurance companies for physicians to work with. The company examined data from the millions of claims it processes for its 40, 000 physician clients around the country.
Performance metrics were based on measurements including payers’ speed in processing claims, denial rates, and transparency in denial explanations.
Keith Martin, executive editor of Physicians Practice said payer performance, which was on the decline after several years of improvement, appears to have reached a plateau, at least for now, “But several coming developments may soon agitate payer-physician relationships: the increased number of patients covered as a result of the Affordable Care Act; the vastly expanding number of medical billing codes in the ICD-10 code set; and increasing adoption of EHR [electronic health record] systems.”
Five Payer Trends
The report picked out five particular trends of note in the analysis of payer performance in 2012:
- Steady private payer days in accounts receivables as compared with 2011 levels—which were significantly worse than in 2010. Denial rates improved falling slightly for private payers, but increased slightly for Medicare. State Medicaid plans continue to perform poorly across multiple metrics. “As millions more payments are processed through the Medicaid expansion going into effect in January 2014 as part of the Affordable Care Act, the inability of Medicaid to process payments efficiently could have dire consequences for provider cash flow, ” athenahealth warns.
- First pass resolve rates fell for the second year, primarily because of HIPAA 5010 (Health Insurance Portability and Accountability Act) conversion problems in early 2012. The rates for all major payers decreased except for Humana and UnitedHealthcare, which stayed constant. National commercial payers were the only group not to decrease on first pass, but did not improve. Some major clearinghouses deviated from standards, which resulted in large batches of rejected claims.
- Provider collection burdens, the amount providers had to collect from patients, again increased, but to a lesser extent than in 2011. However, athenahealth expects acceleration as new health reform requirements take effect, such as state insurance exchanges offering high-deductible plans.
- Insurers continue to struggle to offer electronic enrollment for electronic data interchange, electronic funds transfer, electronic remittance advice and change of address. Two-thirds of enrollment transactions continue to be done via fax or postal mail.
- Many payers do not communicate well on how to participate in their quality incentive programs. Providers cannot find relevant information via a Web search or the phone in a reasonable amount of time. Medicare Part B’s performance for its PQRS (Physician Quality Reporting System) program was just average.
Beware of Medicaid and ICD-10
The expansion of Medicaid will cover individuals in participating states who earn up to 133% of the federal poverty level, or $15, 282 for an individual in 2013. The Supreme Court ruled that states may decline this expansion without pulling out of Medicaid altogether, and by late spring of 2013, 19 states were planning to decline to expand their Medicaid.
Because code mapping isn’t seamless, it’ll be more difficult to send a clean claim through. Providers are encouraged to talk to their vendor to test claims. Providers should be ensuring they have vendors capable of transmitting the expanded ICD-10 standards.
A recent survey of more than 500 physician practices, reported by HealthData Management finds one-third have not started ICD-10 compliance work with the October 2014 deadline looming
Denial Rates
While there was a slight improvement from the previous year with average denial rate declined slightly, to 7.2%, things are about to get more challenging.
Todd Rothenhaus, athenahealth’s chief medical information officer, said that if there is belt tightening on the side of the payers, “there is a return on investment for policy changes that are going to lead to denials. Some of the best payers have particularly low denial rates, but what they were doing was paying everything. While denials are going down nationally, some payers are denying more.”
Minimizing Disruption
There are seven steps you can take to minimize the coming disruption.
1. Track Your Metrics
In dealing with payer denials, understand your own data to spot changes in payer policies as payers require more information about procedures. Emergency medicine physician John Kulin, M.D., told Physicians Practice that he meets with his billing staff on a regular basis to look at the data. “It always tells a story for me. For example, more and more payers seem to give denials or delay payments on anything that’s accident-related.”
Kulin’s practice reduced days in accounts receivable from a high of 60 four years ago to a high of 27 last year.
2. Be Proactive About Co-Pays
Providers are going to have a larger collection burden as the insurance mandates go into effect. Although the collection burden declined for the country’s largest payer, Medicare Part B, it increased for most private insurers for the second straight year.
“Patients are definitely recognizing more costs are being shifted to them, ” says Kulin. “It hasn’t reached the tipping point yet, where it’s dissuaded patients from seeking care, but it may soon.”
A recent report from the American Medical Association (AMA) finds patients now are responsible for almost 25% of their medical costs.
3. Compare Charges Against Receivables
In addition to the challenge of declining payment, payers are cutting their fee schedules. This puts the burden on practices to make sure they are getting paid what payers are supposed to be paying.
Chastity Werner, a billing and collection expert cited in the article, suggests providers select several of their most utilized CPT codes. “Once you have selected the codes, then compare the allowable charges to what was actually received by the payer. Auditing your payers to see if they paid according to contract is essential in a practice’s financial viability.”
4. Grade Against AMA Report Card
There’s an AMA National Health Insurers Report Card to compare your practice to industry standards. An investigation is warranted if payers are below industry standards
The AMA Report Card is based on about 2.6 million electronic claims for 4.7 million medical services submitted in over a two month period to eight insurers: Aetna, Anthem Blue Cross Blue Shield, Cigna, Health Care Service Corp., Humana, Regence, UnitedHealthcare and Medicare. The claims came from 450 physician practices covering 80 specialties in 41 states.
Analysis of the claims data found:
- Insurers are getting more accurate in payments, with an average error rate of nearly 20% in 2010 falling to 7.1% now. Medicare had the highest accuracy rate with 98.1%. UnitedHealthcare led studied commercial payers with a 97.52% accuracy rate, while Regence was last at 85.03%.
- After a big increase in 2012, claim denial rates fell 47% in 2013, from 3.49% to 1.82%. Cigna recorded the lowest denial rate at .54%; Medicare’s rate was nine times higher at 4.92%.
- Humana had the fastest median commercial claims turnaround time at six days with Aetna the longest at 14 days. Medicare has been at 14 days since 2008.
- Between 2008 and 2013, studied insurers have improved transparency of rules to edit claims by 37%, reducing provider administrative costs of reconciling claims.
To view the AMA Report Card, click here.
5. Exact Contract Rate
Make sure you’re getting paid for your exact contracted rate, not just close to it. The article noted a major payer a few years ago that shorted practices a few dollars on certain codes.
6. Balance Payer Mix
Don’t be overly dependent on a single payer.
7. Clean Claims
For example, make sure a doctor’s NPI number is on a claim, and that the patient’s name on their insurance card matches the one on the claim. If the patient’s name is Julie May Smith, and her insurance says J.M. Smith, you better put down J.M. Smith or you won’t get paid. Every time you get a denial, it takes another two weeks to get it right.
Winners and Losers
The ride is going to get bumpy for a while. Those insurance payers who are ranked the highest are probably in the best shape to ride through the ICD-10 and ACA changes. But those payers at the bottom of the lists now…run the risk of falling even further behind.
For physicians evaluating payers, the PayerView tool from athnahealth is an essential tool. And no doubt, for the next few years, the guiding principle for physicians is…Caveat Emptor.
