The data reported here were based on actual physician activity captured throughout the 2010 calendar year on our system. This involved an analysis of approximately 47 million charge lines. Obviously, more charge lines applied to some payers than others, and the number of athenahealth customers submitting to any one payer varied substantially. We included only payers that met a threshold of 4,000 claims per quarter in our system. In addition to requiring a minimum of six clients that submit to a given payer, athenahealth imposed a "client concentration factor" that removed clients that represented a disproportionate volume for that given payer. We report these data as we have found them in our system under these parameters, and we make no representation and do not assert that the data are statistically relevant for any given payer or for payers as a whole or that they are indicative of anything other than the experience that we have observed. In addition to the claims (837) transaction, payers included in the 2011 PayerView results had to support the Eligibility (270/271) and Electronic Remittance Advice (835) transactions.
athenahealth defines "payer" as an organization to which the physician has to submit a claim in order to get paid. This includes a managed care organization, health insurer, military health plan, HMO, preferred provider organization, third party administrator, Medicare/Medicaid plan, and carrier or intermediary to whom physicians submit third party payment claims. Some of these organizations may be forwarding claims to others for actual adjudication, processing, payment or other important steps in the payment process. Since physicians normally cannot bargain for or dictate the terms of these relationships between payers, and since it may be difficult for physicians to track or monitor movement of claims reliably from one payer to another under these relationships, it is our opinion that the physician's vantage point is valuable, and we have therefore arranged the data to generally reflect "payers" to be those entities where claims are submitted by physicians in the first instance.
All of the data reflected on this site are derived from the experience of athenahealth and its customers using athenahealth's claims submission, tracking, and follow-up services. The data represent experience during the data collection period by and on behalf of athenahealth physician clients in transactions with the payers listed and/or in transactions on the claims submitted to the payers listed. The rankings and data presented do not and are not intended to present or ascribe causes for that experience, and "performance" is intended to refer to measure of observed results when claims were submitted using our services to a payer.
As noted above in the definition of payer, the activity of a given payer may vary depending on the role that it assumes in the claim process; and, PayerView data results for a given payer may be caused in whole or in part by the actions or processes of others, including other payers, with whom or for whom the payer in turn conducts business. Similarly, the measures chosen for performance are affected by time lags, mistakes, processing practices and data quality on the part of the physician practices involved, by athenahealth itself and by third parties who act as intermediaries in the transmission of claims information. In some cases, such intermediaries are specified or approved by the payer; and, in other cases they may be chosen by other intermediaries or by athenahealth and may be outside of payer control. We actively work to identify and to address matters that we or our customers can control that affect these and other measures, and we have adopted processes that differ from others in the industry. The performance metrics experienced with the same payers by other physicians using other services may have differed materially for the data collection period.
The reasons for results on any of the measures reported in this site are likely to be complex, and athenahealth looks forward to working with any payer to identify and eliminate causes of adverse experience in any of the reported categories.
To set overall national and regional rankings, we weighted each measure, placing a priority on fast, complete payment. The weighting reflects our opinion as to the impact each measure has on the ability of athenahealth and its providers to receive payment on claims.
The average time it takes to receive payment as measured from the date of charge entry to remittance post.
PayerView's DAR measures cash flow by dividing the average dollars outstanding by the average daily charge. This measurement encompasses the period from the day a charge is entered into athenaNet to the day payment for a charge is posted. This includes any lag time that was caused by athenahealth or its clients in the transmission and posting process. This lag time is one of several ways this metric could have been influenced by matters outside the control of the payer. However, we believe that claim submission and posting procedures tend to impact the outcome consistently across payers, making data comparative and therefore instructive.
Percentage of claims that are successfully resolved on the initial submission (e.g., paid or deemed as patient responsibility by the payer).
"First Pass Resolved" claims are classified as receiving full or partial payment and/or deemed as patient responsibility by the payer on the initial claim submission. Partial payments count as a positive outcome only if the payer communicates that no outstanding amount is remaining. Because athenahealth's client base is a subset of the national provider base, these figures may differ from the national average. However, due to the efficacy of our payer rules engine, which is the largest in the industry, we believe that the rates of resolutions associated with athenahealth services are above the industry average.
Percentage of allowed 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.
A shift in financial burden is imposed on providers when they need to manage collections from the next responsible party after the time of service. Given that providers have few point-of-service tools to manage this growing segment of their revenue stream, it is important to measure what percentage of liability is only available after a patient's visit and requires providers to incur additional costs to collect those payments.
Percentage of claims requiring back-end rework.
The more rework involved with a claim, the longer it takes for the provider to get paid and the greater the resources required by physicians to arrange payment. To measure the frequency of these events, PayerView calculates the number of outright denials for claims submitted to each payer, as well as the line items that require reworking. Because we define denials in this calculation as all claims requiring back-end work, this metric may include claims at the payer pending additional information. Moreover, since back-end work is applied by physicians or by athenahealth, there may be subjective factors that affect this percentage. However, we believe these factors tend to impact the outcome consistently across payers.
Percentage of electronic remittance advice (835) denial messages with actionable explanations and clear next steps.
This metric, which is new this year, reflects how well the payer has adopted the HIPAA 835 standard codeset by returning clear adjustment reason codes accompanied by remark codes as appropriate, for claims that are denied. It is important to note that this metric focuses on a payer's ability to reflect its denial criteria through the use of a standard codeset. This metric does not address other issues (i.e. balancing) that have plagued the industry at large. The inclusion of the ERA metric, along with the revised eligibility metric, brings more visibility to the full HIPAA transaction suite.
The correlation between the payer's eligibility response and adjudication outcome of the claim. If the expected adjudication outcome does not match the eligibility response, then a penalty is assessed.
New this year is the inclusion of the "Other Payer" segment. This segment highlighted the value that the eligibility transaction could provide in preventing coordination of benefit (COB) denials. Data suggests that the eligibility transaction has significant potential in providing transparency into plan design and coverage. The inclusion of this revised Eligibility metric, along with the new ERA metric, brings more visibility to the full HIPAA transaction suite.
Components that contribute to a payer's Eligibility Accuracy loss are:
Eligibility Response/Claim Adjudication Outcome
Eligibility transactions are most effective and useful to providers when they are available (i.e., do not encounter persistent downtime or unverified patient responses) and reliable (i.e., the eligibility response indicates how we can expect the claim to be adjudicated). It is important for payers to return a reliable and detailed eligibility response so that providers can identify and resolve eligibility related issues before submitting the claim to the payer.