CHICAGO – The American Medical Association says more healing is needed before it can pronounce healthcare's claims process cured.
A key problem is inconsistency, highlighting the need for standardization, the AMA says.
The patient has improved, AMA officials said Tuesday as they released their second report on national health insurers, but there "is a tremendous opportunity for improving efficiency."
The AMA released its second National Health Insurer Report Card as part of the organization's Heal the Claims Process campaign. The report diagnoses the strengths and weaknesses of the claims processing systems used by the nation's largest health insurers.
The findings are based on a random sampling of approximately 1.6 million electronic claims for approximately 2.5 million medical services submitted in February and March 2009 to Aetna, Anthem Blue Cross Blue Shield, Cigna, Coventry Health Care, Health Net, Humana, Medicare and the UnitedHealth Group.
"We are encouraged that health insurers took the AMA's initial report card findings seriously and made improvements, but the new results from this year's report card shows there is still work to do," said AMA board member William A. Dolan, MD. "Each insurer uses different rules for processing and paying medical claims that results in confusion and inconsistency. Simplifying the administrative process through standardized processing and payment requirements is needed as part of comprehensive health reform legislation this year. It will reduce unnecessary costs in the health system and eliminate the variability that requires physicians to maintain a costly claims management system for each health insurer."
The inefficient and inconsistent claims process adds as much as $200 billion annually to the healthcare system, the AMA contends. One recent study estimates physicians spend the equivalent of three weeks annually on health insurer red tape. To keep up with the administrative tasks required by health plans, physicians divert as much as 14 percent of their revenue to ensure accurate payments from insurers.
CRITICAL GOALS
Key findings from the 2009 National Health Insurer Report Card include:
Denials. The inconsistency found among health insurers in 2008 continued in 2009. The wide variation in how often health insurers deny claims, and the reasons used to explain the denials, indicates a serious lack of standardization in the health insurance industry.
Timeliness. Prompt payment laws are effective in encouraging insurers to respond to physician electronic claims with relatively quick payment transmittals. Five of eight insurers showed a slight improvement from last year in reducing the median time necessary to respond to a physician claim.
Accuracy. While there remains room for improvement, health insurers made progress in eliminating unnecessary reporting discrepancies from the payment process. Private health insurers correctly reported the expected contracted rate to physicians 72 percent to 93 percent of the time in 2009, compared with 62 percent to 87 percent in 2008.
Transparency. Payers have made improvements since 2008 in their efforts to disclose vital policies and information to physicians through their Web sites. Almost every insurer provides physicians with at least some access to a range of payment policies, with the notable exception of policies related to prior-authorization of services.
