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Humana is the only national commercial payer in the Top 10

Humana is the only national commercial payer in the Top 10, slipping to third behind regular top performers Health Partners and Group Health Cooperative. For 2015, the Blues (Blue Cross/Blue Shield) and small regional payers have the strongest presence in the Top 10.

Provider-sponsored health plans performed as well as top commercial payers in 2014, including a number-five ranking for first-year PayerView participant Maryland Physician Care MCO. Interestingly, top PayerView performers primarily matched those defined as providers’ most trusted payers in the ninth annual National Payor Survey conducted by ReviveHealth, a leading integrated marketing communications firm specializing in health systems, health services, health technology, and healthy living. 

Payers perform well despite market turbulence 

Market pressures in 2014 presented unknown risks to providers and payers. ACA taxes, fees, medical loss ratio, and the influx of newly insured patients through Medicaid Expansion and Health Insurance Exchanges were just some of the factors that could have impacted payer performance. Top-performing payers, however, were able to navigate those challenges. In fact, most did well on traditional metrics such as days in accounts receivable (DAR), first pass resolution rate (FPR), and denial rate. Only when we investigate metrics such as benefit reliability do we see a much wider performance range, with health insurance exchange payers scoring 87% and non-exchange payers scoring 78%. 

For more information on patient utilization and payer mix in response to the health insurance exchanges and Medicaid expansion, see our latest publication by athenaResearch, “Observations on the Affordable Care Act: 2014”.

Payers offering health plans in health insurance exchanges (HIX) performed better than those payers that didn’t

Blues and commercial payers offering health plans in the exchanges performed better than non-HIX carriers in 2013 and 2014. Non-HIX payers must focus on benefit reliability to avoid slipping further behind. HIX payers need to improve DAR and eligibility accuracy to stay ahead of the non-HIX payers.

How payers can succeed in the future of health care

As we look to the future of health care, there are three areas where payers can make a positive difference for providers. 

  1. Payers that return high eligibility accuracy and have strong benefit reliability will be better able to support providers as they collect higher patient obligations, especially for new, high-deductible and tiered health plans.
  2. Payers can work with providers to streamline existing financial, transaction, and administrative workflows today, are in a better position to take on payment reform tomorrow.
  3. Payers that are considered trustworthy, and that perform well during the potentially disruptive shifts to ICD-10 will have the advantage in future joint initiatives with providers.

Medicaid expansion states outperform non-expansion states

Although some states resisted Medicaid expansion and establishing health insurance exchanges, it turns out Medicaids in expansion states performed better than non-expansion states. Compared to last year, expansion states out-performed non-expansion states in provider collection burden, benefit reliability, and first-pass resolution. And expansion states improved most in overall score.

50% of the 2015 Top 10 changed from last year

5% Overall improvement in benefit reliability

27 average overall DAR for health insurance exchange payers

We're ready for
ICD-10 now.

Expansion states improved most in overall score

For more financial information on athenahealth, visit our Investor Relations page.

Every athenahealth provider is on the same, single source of continuously updated cloud-based software.

Driving results

Ensuring ICD-10 readiness

Our Payer Performance Team is conducting testing and tracking payer readiness for the ICD-10
transition, ensuring that all payers receive claims in
the format they need – whether they’re ready by October 1 or not. Through our work behind the scenes, we’re guaranteeing providers that they
won’t be negatively impacted by the ICD-10
transition.

ICD-10 Guarantee

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In the meantime, please feel free to give us a call at 800.981.5084, explore the site or check out a video.

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