Payerview 2016: Collaboration is key
athenahealth® is proud to present the 2016 edition of PayerView, our annual review of the performance of the largest payers in our network.PayerView is more than just an industry report card. We offer this year’s insights with an accompanying infographic that identifies strategies to help providers and payers zero in on opportunities for collaboration in our changing health care world. As the shift from Volume to Value accelerates and the implementation of health care reform continues, now is the time for payers, providers and stakeholders to work together to address new challenges. View the PayerView 2016 infographic.
What the data showsThis year's analysis reveals shifts among payers who have historically been top performers in PayerView. In addition, many more payers met the inclusion criteria for PayerView for the first time this year, 29% more than in 2015. Several Blues and Medicare Part B payers had outstanding performance this year – making for an impressively diverse Top 10 overall.
National Commercial Payers: Powerful Administrative PerformanceThe robust experience and processes of the biggest commercial payers may be what drives their strong performance on administrative metrics. These payers also continue to adapt by engaging in mergers, acquisitions and the vertical integration of technology capabilities. New platforms and technologies present opportunities for innovation, collaboration and communication among payers, providers and other stakeholders.
Blues: Continuing a Trend of ExcellenceBlues have established a trend of outstanding performance, especially on administrative and transactional metrics, such as Days in Accounts Receivable (DAR), Denial Rate and Enrollment Efficiency. Facilitating easier provider enrollment and processing claims rapidly ensures providers get paid fast. Three factors appear to be largely responsible for the Blues’ consistent success: leveraging collaboration across the Blue Cross Blue Shield Association and parent companies; focusing on quality improvement efforts, including sharing of best practices; and centralizing guidance on key initiatives (e.g. ICD-10).
Medicare Part B Payers: Leaders in First-Pass Claim Resolution
Medicare Part B payers benefit from strong, standardized claims adjudication systems and clear payment rules, allowing intelligence to be built into athena’s network and resulting in the highest rate of claims successfully paid on the initial attempt. In the event a claim is denied, clear actionable remittance advice avoids costs associated with follow-up activities and lowers call volume for payers and providers. Looking ahead, Medicare has set an ambitious goal of linking 50 percent of payments to alternative payment models like Accountable Care Organizations by 2018 - so Medicare Part B payers’ robust infrastructure should continue to evolve to support providers.
Medicaid: Some Success in the Face of Unique Challenges
Medicaid payers, which include both state Medicaid programs and Medicaid Managed Care Organizations (MCOs), face unique challenges: administering a complex eligibility determination process, providing benefits to a member population undergoing consistent “churn,” and of course scaling up programs and services in states that opt for expansion under the Affordable Care Act. Despite such challenges, Medicaid payers as a group perform well on the Eligibility Accuracy and Provider Collection Burden metrics, but have room for improvement on most others.
Opportunities for collaboration in a changing health care marketplaceHow can payers, providers, and other stakeholders respond to the changes currently underway in the health care marketplace? For one, they can embrace new tools and transactions to expedite complex processes. Patient eligibility and obligation determination, both growing more complicated with the wholesale rise in cost-sharing and the growth of new network arrangements, are long overdue for simplification. For another, they can take a fresh look at automating elements of frequently tedious manual workflows to achieve efficiencies and free up time for care delivery. Processes such as prior authorization and credentialing could benefit from a collaborative approach.
The health care landscape is ever-changing and increasingly complex. As we look towards the future, in order to become more effective and efficient, collaboration between payers, providers and other partners such as athenahealth will be crucial to staying ahead of ongoing changes across—and beyond—the continuum of care.
Methodology and Metrics
PayerView ranks the largest payers in the athenahealth network on their performance on the financial, administrative, and transactional metrics shown below. For 2016, a payer’s overall ranking is determined as a weighted average of its ranks on the eight individual metrics, based on performance during calendar year 2015.
2016 PayerView metrics
** Payerview® Notice of Disclaimer and Methodology
The rankings and data provided herein are based solely on actual claims activity captured in the athenaNet® system from a limited set of physicians and payers. Rankings and data presented should not be relied upon or assumed to be representative of future experience, or of the experience of physician practices that do not participate in our services. View the full disclaimer and methodology.
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