Want to Know Which Health Plans Rank Highest in Physician Satisfaction?
[Posted 06/15/06]

CMA affinity partner athenahealth recently released a health-plan ranking system that scores health plans based on how they process physician claims. The system ranks plans in seven categories, including speed of payment, denial rates, and first-pass pay rates.

Athenahealth provides web-based practice management services, which includes eligibility verification, claims submission, and insurance collection. The PayerView index ranks claim performance based on data from the fourth quarter of 2005 collected by athenahealth on more than 7,000 national and regional payers.

The system allows physicians to view the health plan rankings nationally or regionally. As a favor to CMA, athenahealth has provided the association with California-specific rankings, as well.

The experience of individual California physician practices may differ from the following, depending on a number of factors, including: the level of completeness and accuracy of claims they submit and the aggressiveness of their follow-up. However, the variations noted below are noteworthy as the billing and collection practices used for the claims submitted in this sample represent best practice and were consistently applied for all payers. The following are the worst and best of the 10 California payers for whom data was reported. (This includes payers for whom athenahealth had at least 3,000 transactions in the 4th quarter of 2005.)

Speed of Payment: The time elapsed between the date of service until the claim was paid (Days in Accounts Receivable “DAR”) differed by nearly 40 days between the best and worst payors.

Ease of Payment: Measured by the percent of claims that were paid on the first submission – requiring no additional information or reworking of the claim by the physician practice. (First Pass Pay Rate “FFP). The best experience was 9 out of 100 claims requiring the practice to resubmit the claim or provide additional information. The worst was approximately two times that.

Claims Processed in Accordance with National Coding Standards: Claims for which coding was correct, based on CPT guidelines and compliant with correct coding conventions but were paid at a different rate or claims processed with $0 payment. These claims are appealable, but impose hassle and require time from the physician practice. The best experience was less than 0.5% of the services paid. The worst was more than 6 times worse.

Denied Claims: Claims that should have been paid and will require reworking and resubmission. The best payor denied one claim out of 20. The worst denied more than one out of five.

Claims Requiring Phone Call Follow Up: These payors used unclear explanations for their adjudication of the claim, necessitating a follow up to identify the steps required to correct it and get it paid. Follow up calls were required on fewer than one in 33 for the best payor and one in 5 for the worst.

Claim Not on File: Claims submitted by the physician office that are either lost in transit or not recorded by the payor upon receipt is occurring less often, but remains a worthy problem. For the best payor, this occurred in fewer than 1 in 900 claims. For the worst, one claim in 68 could not be found.

Using athenahealth’s ranking that gives greatest weight to the speed by which claims are paid without intervention by the practice, United Health and Medicare performed the best for the 4 th quarter of 2005 and Medi-Cal and Blue Cross performed the worst. For more information about athenahealth and how it earned CMA’s endorsement, please call 916/551-2061.

Contact: CMA’s Center for Economic Services, 916/551-2061.