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Reducing Healthcare Administrative Burdens and Costs
Staff Writers
To help reduce the administrative burden of ensuring accurate insurance payments for physician services, the American Medical Association [AMA] recently launched the “Cure for Claims” Campaign [CCC] and unveiled the first AMA National Health Insurer Report Card on claims processing.
Goals
The goal of the AMA campaign is to hold health insurance companies accountable for making claims processing more cost-effective and transparent, as physicians divert substantial resources – as much as 14 percent of their total revenue – to ensure accurate insurance payments for their services.
The National Health Insurer Report Card [NHIRC]
The AMA’s new National Health Insurer Report Card provides physicians and the public with information on the timeliness, transparency and accuracy of claims processing by health insurance companies. Based on a random sample pulled from more than 5 million electronically billed services, the NHIRC examines the claims processing performance of Medicare and seven national commercial health insurers: Aetna, Anthem Blue Cross Blue Shield, CIGNA, Coventry Health Care, Health Net, Humana and United Healthcare.
Study Results
According to the June 16, 2008 AMA study:
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There is wide variation in how often health insurers pay nothing in response to a physician claim (from less than 3 percent to nearly 7 percent), and in how they explain the reason for the denial. There was no consistency in the application of codes used to explain the denials, making it expensive for physician practices to determine how to respond.
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Health insurers reported to physicians the correct contracted payment rate only 62 to 87 percent of the time. When health insurers report an amount that does not adhere to the contracted rate, it adds additional, unnecessary costs to the physician practice to evaluate the inconsistency.
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More than half of health insurers do not provide physicians with the transparency necessary for an efficient claims processing system.
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There is wide variation among payers as to how often they apply computer generated edits to reduce payments (from a low of less than .5 percent to a high of over 9 percent). Payers also varied on how often they use proprietary rather than public edits to reduce payments (ranging from zero to as high as nearly 72 percent).
Assessment
The use of undisclosed proprietary insurance claims edits, only serve to inhibit the flow of transparent information to physicians, adding additional administrative costs to reconcile their health insurance claim issues.
Conclusion
Your thoughts and comments are appreciated. Will likely outcomes of the CCC and NHIRC be real, or illusionary?
Related Information Sources:
Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759
Physician Financial Planning: http://www.jbpub.com/catalog/0763745790
Medical Risk Management: http://www.jbpub.com/catalog/9780763733421
Healthcare Organizations: www.HealthcareFinancials.com
Health Administration Terms: www.HealthDictionarySeries.com
Physician Advisors: www.CertifiedMedicalPlanner.com
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Filed under: Health Insurance, Healthcare Finance, Quality Initiatives, Surveys and Voting | Tagged: health claims, Health Insurance, medical billing, medical invoice |
The Leading Business Education Network for Doctors, Financial Advisors and Health Industry Consultants 
Hi All,
Did you know that a congressional probe found that 27,000 doctors, hospitals, nursing homes and hospices – paid by Medicare – failed to pay more than $2 billion in federal taxes in 2006?
Of course, Medicare officials now say they are taking steps to stop the abuse, according to the Wall Street Journal on June 20, 2008.
The Government Accountability Office reported that the total included $896 million in payroll taxes and $581 million in individual income taxes, and said its own numbers are substantially understated because it didn’t include all Medicare providers, among them those that didn’t file tax returns. The report, ordered by the Senate Homeland Security and Governmental Affairs Committee’s investigations panel, is the result of the third tax-fraud probe involving health care providers. Last year, the GAO found 21,000 of Medicare’s doctors and outpatient services owed $1 billion in taxes through September 2005, and 30,000 providers of Medicaid services owed more than $1 billion through September 2006.
What do you think of that? This takes the CCC and NHIRC to the next level, doesn’t it.
Best
-Jane
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