Three Common Reasons Why Some Insurers Don't Pay Fast Enough

Les Masterson, for HealthLeaders Media , June 19, 2009

Health insurers are paying physicians 5% faster and denying 9% fewer medical claims than last year, but some payers still have a ways to go, most notably state Medicaid programs, according to athenahealth's fourth annual PayerView Rankings.

The Internet-based provider of business services to physician practices evaluated 172 national, regional, and government payers in 40 states, which was the largest data set to date. The company used performance data from more than 18,000 medical providers and $7 billion in charges billed in 2008.

Athenahealth found that many payers are collaborating more with physicians to automate various claims and billing work, while reducing administrative costs and streamlining claims processing. That allows providers to focus more on delivery of care. Jeremy Delinsky, vice president of athenaNet Intelligence for athenahealth in Watertown, MA, says health insurers should focus on reducing administrative waste from the healthcare system.

He adds it's up to stakeholders to remove inefficiencies or someone else—such as the federal government through the proposed public insurance option—will.

Through its research, athenahealth found these trouble spots often lead to delayed physician payments:

  • Health insurers' varied policies and procedures for claims submissions and payment that can cause confusion in physician offices.
  • Real-time claim adjudication that don't help practices integrate the technology into their workflow, but is really a euphemism for additional work for practices, such as needing to rekey information onto the payer's Web site.
  • Insufficient resources for providers, including inadequate call center staff, which makes it difficult for offices to research and/or follow claims, leading to misinformation and additional phone calls to resolve the issues; outdated and difficult to find provider manuals and other documentation; and incomplete information that doesn't provide enough insight to help offices learn where they may have made mistakes in the process.

Humana is tops
Humana topped athenahealth's rankings for the second time in four years and garnered the top spot in fewest days in accounts receivable for national payers. Humana edged out Aetna and Cigna, the highest rated national payers in the 2007 and 2006 athenahealth results respectably.

Mark Smithson, vice president of provider process and network operations at Humana in Louisville, KY, points to two reasons for the high marks: real-time claim adjudication and electronic remittance devices. Smithson says many health insurers say they have real-time claim adjudication, but still require physician offices to log onto the payers' sites and rekey in the information. This merely adds work to physicians' offices. Instead, insurers should integrate the claim adjudication process into the physician offices' practice management system, he says.

"We don't change dramatically how they put their charges in," he says. "Not only does it help at the patient collection window; it also speeds up the entire process."

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