Measurement is the first step to improving health care reimbursement.
PayerView offers unprecedented insight into the complex health care supply chain, shedding light on health care reimbursement process improvements and breakdowns where they occur and clarifying 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. When claims submitted to a payer were paid quickly and fully, the payer tended to do well in the overall ranking. 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 metrics used to calculate payer scores now include these nine metrics:
- Days in Accounts Receivable (DAR) (20% of total score) Average length of time it takes to receive payment as measured from the date of charge entry to the date of remittance post.
- First-Pass Resolve Rate (FPR) (20% of total score) Percent of claims that are successfully resolved on the initial submission (i.e., paid or transferred to patient responsibility).
- Provider Collection Burden (15% of total score) Percent of charges transferred from the primary insurer to the next responsible party. Includes co-insurance, deductibles, and other transfers (e.g., non-covered services). Co-pays and Real Time Adjudication (RTA) amounts are not included in the rate as this information is readily known at the time of service.
- Denial Rate (15% of total score) Percent of claims (both pended and denied) that require the practice to perform back-end rework.
- Enrollment Efficiency (0% of total score this year) Quantitative ranking of administrative burden surrounding provider enrollment in electronic transactions. Ranking considers quantitative scores for enrollment in EDI, ERA, EFT, & PAYTO. Scores assigned based on enrollment type, signature requirements, and submission method.
- ERA Transparency (15% of the total score) Percent of electronic remittance advice (HIPAA 835) denial messages with actionable explanations and clear next steps. Reflects how well the payer has adopted the HIPAA 835 standard code set by returning, as appropriate, clear adjustment reason codes accompanied by remark codes.
- Eligibility Accuracy (15% of total score) Correlation of eligibility response to adjudication outcome. Measures how well the payer’s eligibility transaction predicts the outcome of a claim. Eligibility loss categories are:
- Patient eligible – claim denial
- Patient ineligible – no claim denial
- Patient not found – no claim denial
- Other payer info received – no coordination of benefits (COB) denial
- No other payer info received – COB denial
- Any eligibility transaction attempt when the payer’s eligibility system is not available due to unscheduled downtime.
- Benefit Accuracy (0% of total score this year) Percent of encounters in which payer returns the accurate co-pay amount. Calculated based on co-pays for sick visits to PCPs in an office setting.
- P4P Administrative Burden and Transparency (0% of total score this year) Quantitative ranking of incentive program transparency and quality-neutral administrative burden (e.g., reporting frequency, 3rd party recognition requirements). Administrative burden calculated based on scores assigned for eligibility, reporting, submission, and payment-frequency characteristics. Programs were also evaluated on whether this information, which providers need to evaluate if they are interested in participating, was readily available.
It is important to note that PayerView does not measure the amount of money practices receive from payers; it quantifies, rather, the challenges practices face when collecting from payers for services.