The study analyzed a random sample of 1.1 million electronic claims for about 1.9 million medical services submitted in February and March of 2012. The claims were collected from 380 physician practices in 79 medical specialties in 39 states.
Other key findings:
Denials are on the rise. Medical claim denials are on the rise after recording a downward trend for several years. Only Humana managed a slight reduction in denials. Anthem posted the highest denial rate at 5.1%, while Regence had the lowest denial rate, at 1.4%. A lack of coverage under a patient's benefit plan continues to be the most frequent reason for a denial.
Prior authorization is required more frequently. Only Anthem and Medicare reported a drop in prior authorizations. Regence's request rate is less than 1%, while Humana has a request rate of almost 14%.
Claims are being processed faster. HCSC and Humana had the fastest median response time?six days. Aetna and Medicare had the slowest with a median response time of 14 days.
Transparency has increased. Health insurers increased the transparency of rules used to edit medical claims by 33% from 2008 to 2012. According to the AMA, reducing the use of undisclosed proprietary edits reduces the administrative costs of reconciling medical claims.
I expected that there would be high fives all around between physicians and health plans to celebrate the report's good news, but both sides were quick to point out some shortcomings. For its part, the AMA estimated that an additional $7 billion could be saved if insurers consistently paid claims correctly.
AHIP's Zirkelbach noted that "more work needs to be done to reduce the number of claims submitted to health plans that are duplicative, inaccurate, or delayed."
The annual report card is part of the AMA's "Heal the Claims Process" campaign, which was launched in June 2008 with the goal of reducing the cost of submitting claims for the physician practice from as much as 14% of physician practice revenue to just 1%.