Physicians Practice - June 2008 - (Page 28) FINANCE NATIONAL PAYERS RANK 1 2 3 4 5 6 7 8 PAYER Aetna (2) Cigna (1) Humana (4) Medicare-B (3) UnitedHealth Group (5) WellPoint (6) Coventry Health Care (7) Champus/Tricare (8) Note: Last year’s ranking in parentheses. DAYS IN ACCOUNTS RECEIVABLE 26.86 32.57 30.10 34.54 35.16 36.21 35.71 38.03 RANK 1 3 2 4 5 7 6 8 FIRST PASS RESOLVE RATE 95.64% 95.82% 95.56% 94.25% 95.39% 94.97% 93.29% 93.37% RANK 2 1 3 6 4 5 8 7 PERCENTAGE OF PATIENT LIABILITY 7.72% 8.49% 7.92% 2.06% 7.88% 9.66% 9.93% 3.92% RANK 3 6 5 1 4 7 8 2 • First pass resolve rate. The percent- age of claims that were resolved (either paid or passed on to the patients) the first time they were sent in. Why it matters: This measures how much administrative angst it takes to get paid. What it’s worth: 25 percent of the total score. • Denial rate. The percentage of claims that required back-end work, whether the claim was actually denied or just pending. Why it matters: Whatever the reason for the extra work, it takes you longer to get paid and costs you in administrative time — if anyone on your staff actually bothers to follow up on the payment at all. What it’s worth: 20 percent of the total score. • Percentage of patient liability. How much of patients’ bills are paid directly by patients? Why it matters: Consumer-directed healthcare is a growing trend. But most physician offices aren’t set up to collect in full at the time of service. And, not every payer is set up to give physicians the information they need to do so. What it’s worth: 7.5 percent of the total score. • Claim denial transparency. What percentage of denied claims were paid with just one resubmission? Why it matters: This measures how clearly the payer explains its reason when it denies a claim. What it’s worth: 7.5 percent of the total score. • Percentage of claims requiring medical documentation. This meas- For data on reimbursement levels, head to www.PhysiciansPractice.com, click on tools, and download our 2007 Physicians Practice Fee Schedule Survey Results to get a better sense of what payers should pay — and what you should be charging. JUDGING NATIONAL PAYERS IN SUMMARY The third annual PayerView reveals how easy — or hard — it is to work with payers. ures the rate at which claims are returned by a payer demanding medical documentation. Why it matters: It’s an expensive process, and demeaning for physicians to have to justify their medical judgment to insurance bureaucrats. What it’s worth: 7.5 percent of the total score. • Rate of noncompliance with the correct coding initiative (CCI). Any Based on these measures, Aetna was the best payer for providers to work with in 2007, jumping up from second place last year (see National Payers). Aetna reduced its denial rate 10 percent since last year’s report, giving it the best denial rate among the national payers. It also has, by far, the fewest days in A/R at 26.86, beating its nearest competitor, Cigna, by nearly six days. Paul Marchetti, head of Aetna’s national networks and contracting services, credits transparency for the company’s low denial rates. • Aetna, Cigna, and Humana were the top three performers nationally. Champus/TRICARE came in last. average, for national payers, but decreased for regional payers. poor performance. • Days in A/R increased slightly, on • NPI hassles are to blame for some • Electronic tools smoothed physician-payer relations, especially for regional payers. still on the rise, though more slowly than in past years. Practices need to focus more on patient collections. • Consumer-directed initiatives are physician will tell you that one of the worst things about payers is that each one has its own unique set of rules and coding expectations. We dinged payers when they refused payment on claims because their rules were different than national coding standards. Why it matters: How can any billing office keep track of hundreds of rules from dozens of plans? What it’s worth: 7.5 percent of the total score. We didn’t measure how much payers pay. What we’re getting at here is how hard it is to collect what you are owed. A payer must meet the following criteria to be included in the PayerView index: I Minimum Charge Threshold: • National: 120,000 charge lines per year • Regional: 20,000 charge lines per year I Six or more athenahealth clients must be represented [for data with any given payer]. I Payer must be a “health insurer” (e.g. IPAs and Worker’s Comp are excluded). Includes PPO networks that are responsible for processing/adjudicating the claim. 28 | PHYSICIANS PRACTICE | JUNE 2008 WWW.PHYSICIANSPRACTICE.COM http://www.PhysiciansPractice.com http://WWW.PHYSICIANSPRACTICE.COM
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