Patients Shoulder Nearly 25% of Medical Bills

John Commins, for HealthLeaders Media , June 18, 2013

Denials: Medical claim denials dropped 47% in 2013 after a sharp spike in 2012 among most commercial plans. The overall denial rate for commercial plans went from 3.5% in 2012 to 1.8% in 2013. Among all insurers this year, Cigna had the lowest denial rate at .54%, while Medicare had the highest denial rate at 4.9%. AMA officials have no explanation for the 2012 spike in claims denials.

Timeliness: Plans have improved response times to medical claims by 17% from 2008 to 2013. Humana had the fastest median response time of six days, while Aetna was the slowest with a median response time of 14 days. Medicare's median response time of 14 days has gone unchanged since 2008.

Transparency: Plans have improved the transparency of rules used to edit medical claims by 37% from 2008 to 2013. AMA says reducing the use of undisclosed payer-specific edits unlocks the flow of transparent information to physicians and reduces the administrative costs of reconciling medical claims. .

Robert Zirkelbach, spokesman for America's Health Insurance Companies, did not dispute the accuracy of the AMA report card, but says improving the accuracy and efficiency of claims payments is a responsibility that must be shared by providers and plans.  

"Health plans are doing their part to streamline health care administration to reduce paperwork, improve efficiency, and bring down costs," Zirkelbach said in an email exchange. "A recent AHIP survey found that health plans processed 98% of all claims within 30 days. The AMA report card also found 'dramatic improvements in accuracy,' a 47% drop in claim denials, and improved transparency and response times."

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