Please review this important PayerView Disclaimer information.
We are honored to be named as top payer by athenhealth again this year. This is a reflection of the work we are doing to eliminate the ‘hassle factor’ for health care providers. Humana and athenahealth share the common goal of bringing transparency to health care.
Bruce Perkins
Senior Vice President, Health Care Delivery Systems and Clinical Processes
Humana
Overview
PayerView empowers our industry with important payer rating information.
We know how important it is for payers and medical practices to work together well – not just for their individual financial benefits, but also for the well being of the entire health care system. Until now, however, there has been no objective data to drive improvements. That’s why we started PayerView.
PayerViewSM is an annual project of athenahealth and Physicians Practice.
It’s the industry’s first quantitative report that spotlights payers' performance based on specific metrics. Combined, the metrics provide an overall ranking aimed at quantifying the "ease of doing business with the payer." Needless to say, any data set – including ours – isn’t perfect. But every day, we strive to bring transparency and process integrity to thousands of physicians.
We at athenahealth are committed to bringing transparency to the administrative burden associated with physician payment, and PayerView is proof. Like no one else, we empower clients and practices at large to make payers accountable. Outcomes may include better payer processes, less administrative hassles, streamlined records, less paper, improved cash flow, and better accuracy.
We track the details of every client transaction for thousands of providers.
PayerView is a natural outgrowth of the data that athenahealth dynamically manages and processes on behalf of its clients. Unlike other billing, practice management and EHR solutions, athenahealth uses centrally hosted web-based software tools and behind-the scenes support for clients. So every detail that occurs during a billing transaction – every claim submission, denial, number of days in accounts receivable (DAR) and more – is captured electronically in a secure manner.
We distill our information into quantitative rankings.
Each year, athenahealth draws on this objective, comprehensive dataset – such as how long it takes providers to get paid – to rank the “ease of doing business with” payers. athenahealth widely publicizes the PayerView rankings, and uses PayerView data to collaborate with payers to make improvements in the payer/provider relationship.
PayerView is the industry’s first objective, comprehensive data set that reflects the dynamics that occur across the complex provider/payer supply chain. It sheds light on (and offers hope to) a realm dominated by imperfect data, hearsay and anecdotes.
How medical practices benefit:
- Payer improvements for all providers. Whether or not you’re an athenahealth client, your practice benefits from PayerView. Whenever we help one of your payers improve its days in accounts receivable (DAR) or first pass resolve rate, your practice will see benefit from the ripple effect of their improvements.
- Leverage in payer negotiations. PayerView’s data provides a standard “language” to use with payers. These metrics can become a shared vocabulary for payers and providers to use when resolving issues or negotiating contracts.
- Better control over practice performance. PayerView metrics give you a set of day-to-day variables to measure and track. Using these figures to gauge your practice performance can reveal strategic ways to increase profitability and focus on patient care.
Payers benefit too.
One of the more tangible benefits to payers is the cost savings associated with streamlining claims submission and follow-up procedures. This is the common ground where payer and provider goals are aligned – and where athenahealth has built a conduit to facilitate better relations, patient care, and positive change in our industry.
To learn more, contact athenahealth
Benefits
How PayerView has changed the way providers and payers work together – and how your practice benefits.
Payers and providers have tried for years to respond to increasing demands in the health care industry: greater operational efficiency, stronger profitability, and higher standards for patient care.
Payers and providers may have the same goals, but without objective information to pinpoint problems, it’s been almost impossible to find a mutually agreeable path forward. Until now.
Here are a few improvements we’ve made as a result of the momentum behind PayerView:
Navigating industry transition.
We worked hard to help our providers manage the National Provider Identifier (NPI) initiative. And despite a slight bump in denials and dip in first pass pay rates (FPR) for providers, most payer groups saw impressive improvements. Aetna, Cigna, Humana, and UnitedHealthcare reduced denials by 9% and reduced days in accounts receivable (DAR) by 5.3%.
Streamlined billing for better cash flow.
We’ve undertaken key initiatives to help payers optimize the payment cycle, including making electronic remittance (ERA) and Electronic Funds Transfer (EFT) available to athenahealth’s provider base. These advancements allow providers to streamline their billing and records, reducing paper and improving both cash flow and accuracy.
Increased transparency.
Payers are more aggressively using web portals to give providers access to information once available only on paper or by phone. Payers are also proactively contacting providers about guideline changes, resulting in a decrease in days in accounts receivable (DAR).
To learn more, contact athenahealth
Process
We strive toward objectivity.
Our goal was to rank payers based on how well they worked with our physicians. PayerView doesn’t measure how much payers pay; its goal is to quantify the challenges practices face in collecting for their services. We avoided anecdotes and impressions and focused on hard data of activity in our systems with the physicians and payers with whom we interact. We measured payer performance in seven areas, including:
Financial Performance
- Days in accounts receivable (DAR). The number of days it takes a practice to get paid from the date the charge was entered into athenahealth's system. The calculation is made by taking the average total outstanding A/R and dividing it by the average daily charge.
- First pass resolve rate. The percent of claims that was successfully resolved on the initial submission – meaning they were either paid or determined to be the patient's responsibility.
- Percent patient liability. The percent of billed charges transferred to patient responsibility. This is a proxy for the burden placed on practices to manage patient collections.
Administrative Performance
- Denial rate. The percent of claims (both pended and denied) that required the practice to perform back-end rework.
- Claim denial transparency. The percent of denied claims that were paid with just one resubmission. The aim is to measure how clear the payer is on the reason for the denial.
- Percent of claims requiring medical documentation. The percent of claims that required the practice to attach medical documentation to justify payment.
Medical Policy Complexity
- Percent non-compliance with the Correct Coding Initiative (CCI). The percent of claims not receiving payment as a result of a payer's departure from national coding standards.
Together, these measurements represent athenahealth's opinion of how easy or difficult it was during the data collection period for athenahealth customers to get paid quickly and accurately on claims submitted to the listed payers.
Learn more about our PayerView Methodology
To learn more, contact athenahealth
Trends
There’s a better way to work together.
Medicare’s prominent NPI position.
Medicare took the lead in enforcing the NPI requirement, at the expense of dropping in performance across in both its denial rate and FPR relative to 2007. But as NPI issues with providers were resolved, claims processing time improved. So Medicare actually improved its DAR for the year (from 34.54 days in 2007 to 33.41 days for 2008), and had particularly strong performance in the last quarter of 2008.
Is the lagging economy affecting performance?
Towards the end of 2008, providers entered charges more quickly than last year. This could indicate more diligence about getting paid and resolving denied or unpaid claims as a result of the economic downturn.
Moderate growth in patient liability.
In 2008, all athenahealth payer groups experienced an increase in patient liability – though not as aggressive as the growth cited in many industry forums. The difference could be because industry data reflects the number of enrollees, while athenahealth’s dataset reflects actual dollars owed to providers from co-pays, co-insurance, deductibles, and other patient responsibility such as non-covered services. Blues had the highest patient liability in 2008 at 9.17% (a growth rate of 2% over last year), and the major nationals – Aetna, Cigna, Humana, UnitedHealthcare – had the second highest at 8.47% (3.4% growth since 2007).
Providers still lack a universal set of tools to estimate patient responsibility. An exception is real-time claim adjudication (RTA), made available to athenahealth’s providers through a seamless integration with both Humana and United’s real-time claim adjudication platforms. Both payers realized significant performance gains since the national introduction of RTA in 2008. In the years to come, athena will continue to work with providers to integrate time-of-service tools made available to the provider community to determine patient responsibility.
Continued low performance for state Medicaids.
State Medicaids continue to perform well below average. This year, the average state Medicaid’s DAR is two times the average athenahealth payer. Denial rates are three to four times the average payer with an average denial rate of 21.73% in 2008. While FPR is above 90% for most payer groups, FPR is in the low 80% range for the state Medicaids, with some states as low as 60%. The declining economy is expected to further impact state Medicaid performance next year as enrollment may swell.
Payer Highlights
BCBS-RI had the lowest DAR in the nation for the third year in a row and had the lowest denial rate in the nation for the second year in a row. BCBS-RI has created a great deal of transparency in accurate claims processing, eliminating much of the complexity that is typically associated with billing medical claims.
Medicaid-NY dominates the low performers in two key metrics: DAR and FPR. It had the highest DAR in the nation for the third year running, and the worst FPR in the nation for the second year. Major factors in Medicaid-NY's low performance are complex authorization requirements, use of proprietary claims forms, and annual EDI re-enrollment requirement.
To learn more, contact athenahealth
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