Over the past five years, PayerView has turned into a really constructive basis for supply chain partnerships among athenahealth, the physicians that we represent, and the payer community. Most of these payers have used it to dramatically improve the speed and efficiency with which they pay doctors – and they’re benefiting from those improvements as well.
Jonathan Bush
CEO & President
athenahealth
Read our Metric Data and PayerView Disclaimer.
Overview
PayerView. Bringing transparency and process integrity to the health care system.
With health care reform poised to bring massive change and expansion to the U.S. health care system, it is more important than ever for medical practices and insurance companies to work well together. Until recently, there had been no objective data about medical claims billing to reflect the complex relationship between providers and payers and to drive improvements. That’s why we created PayerViewSM.
PayerView is an annual project of athenahealth and Physicians Practice.
It is the industry’s leading quantitative report, providing unprecedented insight into the provider-payer relationship with objective, data-driven methodologies. PayerView data helps create an industry-wide dialogue on how breakdowns in the medical claims billing process can be addressed. The objectives of PayerView are:
- Discovery. We continuously assess and refine the metrics included in our dataset so they highlight provider-payer dynamics that create inefficiency and cost in the system.
- Continuous Improvement. PayerView data informs initiatives aimed at encouraging openness and clear communication between providers and payers about the medical claims billing process.
- Transparency. We provide our client base and payers at large with a comprehensive tool that characterizes the intricate interdependencies in the health care supply chain, helping both the payer and provider to improve.
We track the details of every client transaction for thousands of providers.
PayerView is a natural outgrowth of the unique data that athenahealth continuously compiles and manages on behalf of its clients. Unlike other medical claims billing,
practice management, and
EHR solutions, athenahealth uses centrally hosted, web-based software and provides robust back-office services. So every detail that occurs throughout the provider’s billing experience – patient eligibility check, claim submission, processing time at the payer, claim denials, receipt of electronic or paper remittance and more – is captured electronically and securely across our network of more than 23,000 providers nationwide.
We distill our information into quantitative rankings.
Each year, we distill our extensive medical claims billing data and draw on it to create comprehensive and objective rankings of payer performance. athenahealth widely publicizes the PayerView rankings, and uses PayerView medical claims billing data to collaborate with payers to improve the overall provider-payer relationship.
Reflecting the complex dynamics occurring across the health care supply chain, PayerView brings reliable evidence to medical claims billing, a process long dominated by imperfect data, hearsay, and anecdotes.
To learn more, contact athenahealth
Benefits
PayerView changes the way providers and payers work together – to the benefit of both.
Payers and providers both strive to respond to increasing demands on each other and on the health care industry as a whole – and with health care reform, those demands will only increase. Payers and providers essentially have the same goal – a more efficient and less costly process – but without objective health care supply chain information to pinpoint systemic problems, it’s been almost impossible to find a mutually agreeable path forward.
PayerView provides this objective information. It gives payers an end-to-end view of the claims process that is not available to them individually, enabling them to see where their processes exceed or fall short of industry standards. It gives providers insight into how they can operate more efficiently and effectively and thereby make it easier for payers to process their claims.
How providers and payers benefit:
Payer improvements realized by all providers.
Whether or not you’re an athenahealth client, whenever we help one of your payers improve performance along one of the key PayerView metrics – denial rate, clarity of information returned on paper or electronic remittance – the medical claims billing process in your practice benefits from these improvements.
Cost reduction across the health care supply chain.
Both payers and providers reduce costs by streamlining the claims process. This is the common ground of medical claims billing, where payer and provider goals are aligned – and where PayerView has helped created an industry-wide dialogue to address the places where payers and providers become misaligned.
Better control over practice performance.
PayerView metrics give providers a set of day-to-day variables to measure and track their medical claims billing. Using PayerView to gauge practice performance, providers can increase profitability and focus on quality of patient care.
Here are a few improvements we’ve made as a result of the momentum behind PayerView:
Navigation of industry transitions.
PayerView was critical in measuring the impact absorbed by the industry with the implementation of the National Provider Identifier (NPI) in 2008. While athenahealth’s data revealed that many payers experienced a decline in performance, it was the performance of CMS/Medicare-B that significantly declined due to its leadership position in the enforcement of the NPI requirement. It is expected that athenahealth’s data will reveal equally interesting outcomes with the upcoming upgrade to the HIPAA 5010, which impacts all standard transactions. athenahealth’s ability to characterize the performance of the entire supply chain through its PayerView dataset uniquely positions it to not only measure how well complex industry standards are implemented, but also to help highlight the pitfalls to avoid.
Increased transparency.
PayerView provides a unique window on the end-to-end process of healthcare claims reimbursement and processing. Through its PayerView framework, athenahealth has worked with payers to identify business processes or requirements that negatively impact providers’ daily activities. PayerView has been instrumental in defining the information that is needed by the provider during the course of the
medical billing process to ensure efficient and accurate processing of claims on the initial submission. Some of this information can be relayed through the use of standardized transactions (e.g., eligibility, remittance). Other information is best supported through self-service tools (e.g., payer web portals) made available to the providers. Likewise, the PayerView framework has brought visibility into the impact provider behavior can have on overall performance. For example, while athenahealth assumed a leadership position with its fully integrated real-time claim adjudication capabilities with both Humana and UnitedHealthcare, provider adoption has been slow. PayerView has continuously proven to be a reliable tool that surfaces performance gaps across all components of the health care supply chain.
To learn more, contact athenahealth
Trends
Collective improvement across all payers.
Faster Revenue
– Overall, in 2009 providers realized their receivables on average 7 days faster across all payers than in 2008. After a couple of years leading the industry in implementing the National Provider Identifier (NPI), Medicare B's DAR recovered in 2009, posting, at 25.5 days, the greatest overall improvement. Even Medicaid, traditionally the lowest performing payer, showed a significant decrease in DAR to 56.6 days. This continual overall improvement is believed to be rooted in on-going work to increase efficacy and transparency through standard transactions, along with denial preventions supported by athenahealth's rules database.
Less Work
– As one of the drivers behind decreased DAR, it’s not surprising that there was also a noticeable improvement in the Denial Rate across almost all payers in 2009. Similarly, as the industry adjusted to the new standard NPI requirements, Medicare-B’s denial rate of 6.5% constituted the greatest improvement in the industry. An exception to this improvement was the Blues payer group, which experienced a slight increase in denial rate to 7.9%. The Blues tend to have a higher rate of benefits coverage and patient insurance denials when compared to other commercial carriers. This may be due to patient movement amongst plans within a Blues payer and the nature of Blues' contracts and business structure.
Base Eligibility Transaction is Working
Baseline performance results showed that across all payer groups, reliable eligibility data was returned for basic eligibility checks (i.e., is patient eligible – yes/no?). This was a positive trend in standard ANSI 270/271 usage considering that athenahealth continues to note differences in the application of the ANSI835 transaction (ERA). Several interesting themes emerged:
- Government payers performed on par with commercial payers, with Medicare leading all payers with an average eligibility accuracy of approximately 99%.
- A major driver behind accuracy loss across all payer groups stemmed from unverified patient responses in which the payer was not able to find the patient via an eligibility inquiry, but was later able to do so and adjudicate the claim without incident.
- Baseline measurements indicate that the quality of the eligibility transaction is high. However, there is still room for improvement – particularly around how to apply enriched eligibility transactions towards denial prevention and ultimately DAR and FPR improvement.
Further Leveraging Standard Transactions
athenahealth PayerView 2010 results demonstrate that a fully electronic transaction-based supply chain can reduce cycle time and improve overall performance.
While each transaction’s transition from implementation to full utility is a learning experience, review of PayerView results over the recent years show that the greatest benefits of standardized transactions reside not with a specific transaction, but rather in the implementation of the full end to end set of transactions – claims, eligibility, remittance, claim status inquiry, etc.
Payer Highlights
A lens that ranks “All Payers” included in the athenahealth PayerView dataset is new to the 2010 PayerView release. Counter to the belief held that health care is regional, and hence, regional payers should dominate, athenahealth 2010 PayerView results demonstrate that fully utilized transactions coupled with a streamlined supply chain, can lead to competitively high performance results for all types of payers.
Top performers were well-represented by payers from across a variety of groups, signaling healthy competition. The top 10 ranked payers were:
- Blues: BCBS-RI (#1), BCBS-MA (#3), BCBS-OH (#6)
- National Commercial: Humana (#2), United Healthcare (#4)
- Medicare: Medicare B-GA (#7), Medicare B- NC (#8), Medicare B-OR (#9)
- Regional: Tufts (#5), ODS Health Plan (#10)
High Performing Regional and Major National Payers are Neck-and-Neck. Are Standard Transactions Leveling the Playing Field?
As payers transition to fully electronic-based transactions (e.g., Eligibility ANSI 270/271, Claim Status Inquiry ANSI 276/277, and ERA ANSI 835) we see a growing trend where payers are able to leverage these standard transactions and simplify their processes. The New England market is a great example of this trend as evidenced by the dominating presence of Northeast regional payers (BCBS-RI#1, BCBS-MA#3, Tufts#5, and Harvard Pilgrim #14) among the top performers in the All Payers’ segment. A major payer to note is BCBS-RI, which was ranked #1 in the All Payers, Blues, and Northeast segments. BCBS-RI is a dominant payer that operates in a small state. It will be interesting to observe if BCBS-RI will be able to maintain its #1 rank as increased usage and full utility of transactions are employed by the industry at large.
National Commercial Payers Set the Pace
As a group, national commercial payers – Aetna, Cigna, Humana, and UnitedHealthcare – continue to have the best performance across key PayerView metrics. Humana had a banner year, achieving the #1 rank in the following segments: Major Payer, National Commercial Payer, Midwest, and West. Humana was also ranked #2 among all 137 payers included in the 2010 results, making it the best national commercial payer among the athenahealth payer base. A major driver of Humana’s stellar performance was its fully integrated real-time claim adjudication (RTA) capabilities with athenahealth. UnitedHealthcare, which has also fully integrated its RTA capabilities with athenahealth, ranked 4th among all payers.
Medicare Continues its Role as the Steward of Electronic Transaction Compliance
As a group, Medicare-B continues to have solid performance with several states (Medicare B-GA, Medicare B-NC, Medicare B-OR) performing in the Top 10 among all payers included in the PayerView dataset. While Medicare-B has improved its year-over-year performance, Medicare-B’s rate of improvement lags behind that of its national commercial payer peers. This may be attributed to the fact that Medicare, as the federally funded payer, is expected to exemplify the standards. Therefore there’s a greater sense of accountability and transparency into its policies and procedures. Medicare has been a long-time advocate of electronic transaction standards and has played a pivotal role in the industry with respect to enforcement of these standards. This role has often resulted in Medicare absorbing a performance decline, since it often invests in upfront transition costs such as NPI conversions and highly regulated enrollment processes. Across all payer groups, Medicare continues to exhibit the most consistent performance despite shouldering the burden for enforcing industry standards.
To learn more, contact athenahealth
Metrics
We strive to be objective and accurate.
The goal of athenahealth PayerView is to provide objective, data-driven insight into the health care supply chain, into the relationship between payers and providers. We help create an industry-wide dialogue on how breakdowns in that relationship can be addressed on both sides and thereby help move the industry forward.
To set overall national and regional rankings, we measured payer performance across six metrics. We weighted each metric, placing a priority on fast, complete payment. The weighting reflects our analysis of the impact each measure has on the ability of athenahealth and its providers to receive payment on claims.
The six performance metrics and their respective weighting are as follows:
Financial Performance (60% total)
- Days in accounts receivable (25%). The number of days it takes a practice to get paid from the date the charge was entered into athenahealth's physician billing services system to the date of remittance post. The calculation is made by taking the average total outstanding A/R and dividing it by the average daily charge.
- First pass resolve rate (25%). The percentage of claims that was successfully resolved on the initial submission – meaning they were either paid or determined to be the patient's responsibility.
- Provider collection burden (10%). The percentage of billed charges transferred from the primary insurer to the next responsible party. This includes co-insurance, deductibles, and other transfers (e.g., non-covered services). Co-pays and time of service real time adjudication amounts are not included, since this information is readily available to the provider.
Administrative Performance (30% total)
- Denial rate (20%). The percentage of claims (both pended and denied) that required the practice’s physician billing services to perform back-end rework.
- Denial transparency (10%). 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 and the next steps to resolve the claim.
Transaction Efficacy (10% total)
- Eligibility Accuracy (10%). The correlation between the eligibility response and the adjudication outcome. If an expected adjudication outcome does not match the transaction response (e.g., payer states that a patient is eligible in its eligibility response and later denies that patient’s claim for eligibility reasons), then a penalty is assessed.
Click here to learn more about PayerView metrics.
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