Seven Largest Insurers Incorrectly Pay One in Five Claims, Says AMA

Cheryl Clark, for HealthLeaders Media , June 15, 2010

This AMA report card is the organization's third, and Nielsen says that overall, the insurers did improve their scores over last year in a number of measures, but much more improvement is needed.

The scoring was based on a random sample of 2 million electronic claims for 3.5 million medical services submitted in February and March, 2010.

The claims were submitted by more than 200 physician practices in 76 medical specialties in 43 states. The AMA followed up on its survey with a paper suggesting ways commercial plans can improve administrative simplification.

Asked to comment on the AMA's latest report card, spokeswoman Kristin Binns says Anthem's parent company WellPoint appreciates the AMA's input and to improve its score it has contracted with a one-stop-shop company, Availity, in hopes of "streamlining the healthcare administration process and providing a consistent user experience."

Aetna representative Tammy Arnold say her company shares the AMA's goal "to increase transparency and simplicity in interactions between payers and the medical community" and says it is proud of the progress it has made.

CIGNA spokesman Joseph Mondy said the AMA report card shows that CIGNA patients are gettting "just what the doctor ordered service" with claims remittance that was cut in half from the AMA's previous report card from 12 days to six days, improved accuracy in which payment was equal to contracted physician fee schedule and "the lowest rate of claims denials among participating plans," with less than 1% of claims denied in the 2010 period.

Humana spokesman Jim Turner said his company his ocmmitted to working with the medical community to simplify the payment system and was praised by Athenahealth as "easiest payer for doctors to do business with."

HCSC spokesman Ross Blackstone says, "There are many studies of claims processing effectiveness across the industry that employ a range of methodologies. External studies by independent auditors on behalf of employer group customers and other stakeholders have found our financial and payment accuracy to be in the high 90th percentile. We are proud to consistently rank at or near the top."

And Lynne High of UnitedHealthcare Group said the latest AMA survey reflects significant work her company has done to improve service to physicians. "UnitedHealthcare has advanced a number of innovations that seek to reduce administrative burdens for care providers and give them more time to focus on their patients," she says.

Nielsen acknowledges that compared to last year's scorecard, many of the insurance companies have improved their response times for paying doctors. "We're pleased to be able to report that," she says. However, she quickly adds, "there's a lot of improvement that still needs to take place."

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