An annual ranking of insurance companies by athenahealth Inc., based on analysis of claims data from 40,000 physician clients, finds “very modest” improvement in payer performance between 2011 and 2012, according to the vendor.
That continues a trend started in 2011 when for the first time since rankings started in 2005 industry performance remained flat and in some cases decreased. Burdens with conversion to the HIPAA 5010 transaction sets hurt performance in 2011 and continued to do so in 2012. The conversion resulted in lower performance for days in accounts receivables and first pass resolve rates.
There were some new faces in the top 10 performing payers in 2012 after athenahealth employed a new metric weighting system it believes presents a more holistic and accurate reflection of payer performance. Insurers who most benefited from the new metrics included Humana, Tufts, MVP Health Plan of New York and BCBS of the District of Columbia. BCBS of Rhode Island, a perennial high performer, fell out of the top 10.
The top payers, in order, were Humana, Medical Mutual of Ohio, Healthpartners, BCBS Massachusetts, UnitedHealthcare, Medicare Part B in Missouri, Aetna & Aetna-US Healthcare, BCBS in the District of Columbia, MVP Health Plan of New York and Medicare Part B in Connecticut.
Athenahealth picked out six particular trends of note in the analysis of payer performance in 2012:
* Private payer days in accounts receivables remained steady with 2011 levels, which were significantly worse than in 2010. Denial rates improved very slightly for private payers, and decreased slightly for Medicare. State Medicaid plans continue to perform poorly across multiple metrics. “As millions more payments are processed through the Medicaid Expansion going into effect in January 2014 as part of the Affordable Care Act, the inability of Medicaid to process payments efficiently could have dire consequences for provider cash flow,” athenahealth warns.
* First pass resolve rates fell for the second year, primarily because of 5010 conversion problems in early 2012. The rates for all major payers decreased except for Humana and UnitedHealthcare, which stayed constant. National commercial payers were the only group not to decrease on first pass, but did not improve. Some major clearinghouses deviated from standards, which resulted in large batches of rejected claims.
* Provider collection burdens again increased, but to a lesser extent than in 2011. However, athenahealth expects an acceleration as new health reform requirements take effect, such as state insurance exchanges offering high-deductible plans.
* Co-pays continue to increase for commercial insurers. Fourteen payers did well with a new co-pay metric by reporting the correct co-pay amount for a sick visit to a primary care physician in an office setting in more than 98 percent of eligible responses. Many other payers performed well below the median 95 percent accuracy level, with seven that returned correct co-pay information less than 50 percent of the time, and four of them never returning the information. WellPoint Unicare was the best with a 99.4 percent rate.
* Insurers continue to struggle to offer electronic enrollment for electronic data interchange, electronic funds transfer, electronic remittance advice and change of address. Two thirds of enrollment transactions continue to be done via fax or postal mail.
* Many payers are poorly communicating on how to participate in their quality incentive programs as providers cannot find relevant information via a Web search or the phone in a reasonable amount of time. Medicare Part B’s performance for its PQRS program was just average.
The 2013 PayerView Report is available at athenahealth.com/PayerView.
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