Web site tells how fast insurers pay

Even though just about every state has prompt-pay laws, Frederic Ettner, MD, of Evanston, Ill., is one of many physicians who would argue that insurer payments aren't terribly prompt. In his current worst-case scenario, Dr. Ettner said he's in the midst of a six-months-and-still-counting fight with one plan over payment for a mere office visit.

Dr. Ettner's experiences, and the experiences of many other doctors, are being confirmed by a newly released health-plan ranking system that breaks down which insurers are the most responsive to physicians, and which are not.

Athenahealth, a Watertown, Mass.-based claims processing company, developed what it calls the PayerView ranking system, which can be viewed online (link). The system ranks plans based on seven categories, including days in accounts receivable, denial rates and first-pass pay rates.

Those numbers are converted into an overall metric used to rank plans nationally and regionally, as well as ranking Medicare- and Medicaid-based plans. The plans also are ranked based on their performance in each of the seven categories.

Kim LaFontana, Athenahealth's vice president, said the company wanted to use the data to let the insurers know what it's like to do business with them. Athenahealth plans to use the information to work with insurers on problem areas -- and also, perhaps, drum up a little physician business for its practice management services along the way.

Athenahealth, in partnership with the practice management journal Physicians Practice, used data from more than 7,000 doctors collected during the fourth quarter of 2005 to determine how efficiently insurance companies processed physician charges.

The most efficient national plan, it found, was Humana. The least was WellPoint. Athenahealth plans to update its information and rankings quarterly.

While Humana crows and WellPoint grouses about its ranking, the PayerView system gives some tangible evidence physicians can use as they ask why, with prompt-pay laws in effect, is it so hard to get paid? According to Athenahealth, between 5% and 35% of claims will never be collected, even though physicians spend as much as 10% of their revenue trying to collect those claims.

Not so prompt

South Carolina is the only state without a law requiring insurers to pay claims in a timely manner, according to the AMA. It says health plans have been fined a collective $70 million for prompt-payment law violations.

Yet collection is still a problem. The laws generally dictate a deadline for plans to pay physicians for a clean claim. The problem is that the rough definition of a clean claim -- one in which all information submitted is correct -- is very rough indeed.

Dr. Ettner said that in the case of his six-months-and-counting wait for an office visit payment, the insurer keeps asking for medical records, notes from the patient's chart and other information repeatedly that the insurer says it needs to verify the veracity of the claim.

"I feel powerless," Dr. Ettner said. "I feel relegated to being a clerk -- not a physician."

The AMA is encouraging state lawmakers to tighten their prompt-payment statutes "to prevent delays that place claims in limbo," said outgoing AMA Board Chair Duane Cady, MD. Holding health insurers accountable for paying promptly is "increasingly a challenge as health plans find ways to circumvent prompt-payment laws."

The PayerView system gives physicians useful information to determine which plan might create the most hassles, helping physicians decide what kind of relationship they want to establish -- or continue -- with an insurer, said Nileen Verbeten, the California Medical Assn.'s vice president for economic services.

"It's not the only measure that a payer can be judged [on]; it provides a measure of difficulty that a payer uses. It arms the physician to know what to expect from a payer. It gives them something to compare their own experience with."

Checking the rankings

Humana got its top national ranking of 93% thanks in part to having the lowest days-in-accounts-receivable level (29 days), the lowest denial rate (7.3%), and -- tied with Aetna -- the lowest not-on-file rate (0.2%), meaning claims that got lost in transit. A 29-day average is almost twice as high as the 15-day deadline some states give plans to pay clean claims, though other states allow up to 45 days.

WellPoint's bottom ranking of 84.5% came courtesy of having a ranking no higher than third in any metric, including a last-place ranking (9.5%) in the share of charges billed back to patients.

In a prepared statement, Humana touted the survey as proving its commitment as the "best payer with which to do business." Meanwhile, WellPoint spokesman Jim Kappel said Athenahealth's analysis was flawed in a number of ways, particularly because of the number of claims WellPoint processes.

He said WellPoint processes more charge lines per day than the 5 million lines Athenahealth processed for the entire study. Also, he said WellPoint ranks higher than its competitors according to a customer satisfaction survey by an outside firm retained by the company.

Each plan measured through the PayerView system shows it's better at some things than others. For instance, the category that shows the percentage of claims requiring the physician's office to call the health plan for clarification or corrective action puts TRICARE, at 3.5%, first among national plans. But at 85.1%, TRICARE ranks last for first-pass pay rate, the percentage of claims paid as submitted within 90 days.