Rating insurers will help fix inefficient claims system

These days, it seems that physicians are being graded by everyone but their former high school teachers.

Doctor-rating Web sites allow patients to chime in on their physicians, giving a platform for unfiltered remarks about long waiting room times, poor communication and other complaints.

Patients can rate their doctors on Angie's List, next to reports about plumbers, florists and locksmiths. And a Zagat ratings system lets patients rate physicians basically the same way they would restaurants.

Meanwhile -- less colorful but hitting closer to home -- physicians and insurers continue to spar over data that are being used to create doctor ratings and tiered health plans.

Well, turnabout is fair play, and physicians deserve a rating system that delivers what they need to know both to run their practices and to serve patients. Now, the American Medical Association has provided just that.

In June, the Association issued its first National Health Insurer Report Card on claims processing. The AMA said the report card gives doctors and the public a reliable source of data on the transparency, timeliness and accuracy of claims processing by health insurance companies.

The report was based on data from 5 million claims billed electronically to Medicare and seven commercial health plans: Aetna, Humana, Cigna, WellPoint-owned Anthem Blue Cross Blue Shield, Coventry Health Care, Health Net, and UnitedHealth Group-owned UnitedHealthcare.

The findings: Insurers' claims payments are often late and inaccurate, denial explanations are inconsistent, and payment rules are sometimes impossible to interpret. Insurers reported to doctors the correct contracted payment rate 62% to 87% of the time, according to the report. About half do not give doctors the transparency needed for an efficient claims processing system.

The AMA said the report card shows the confusion and inconsistency that stem from insurers using different processing and payment rules. That approach forces doctors to keep a costly claims management system for each insurer.

The report card was unveiled during the AMA Annual Meeting. The Association also launched the "Heal the Claims Process" campaign, designed to fix a claims-payment system that frustrates physicians. The AMA said doctors spend as much as 14% of their total revenue on claims administration, and the Association wants to get that figure lowered to 1%.

The campaign is a good start to ridding the process of inefficiencies and unnecessary costs to the health care system. It encourages doctors and their staffs to submit claims in a timely and accurate manner the first time. And payers should pay in a similar prompt and correct fashion with full transparency concerning fee schedules and medical payment policies.

The AMA has a "Heal the Claims Process" Web site that provides physicians with practical tools and educational materials (link). November will be "Heal That Claim" month, a time when the AMA will encourage doctors to review and reconcile their claims.

With the new initiative, doctors and insurers have a prime opportunity to fix an ailing claims system. It's time that physicians get paid by insurance companies in a timely manner so doctors can deal less with claims and more with patients. That's something that would garner four stars among physicians.