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CloudView blog

Ideas and insights to help health care providers stay informed and profitable in today's challenging health care environment.

PayerView 2011 – Aetna on the Rise

by Melissa Lukowski, Director of Payer Outreach

The athenahealth 2011 PayerView rankings are finally in! Before we dig into the findings, here’s a bit of background on PayerView and how it works.

This year’s PayerView results come from the actual medical claims billing experience of our 27,000+ providers. That means 47 million charge lines and $9 billion dollars in charges submitted throughout the 2010 calendar year. Services were billed from 41 states to 132 payers that met key criteria like claim volume threshold and client concentration. To get more detail on how PayerView works, what metrics we’ve measured, and to probe the rankings in depth, click here.

OK, the rankings. The 2011 PayerView results reveal some very interesting trends that came to light with the addition of HIPAA transaction metrics like electronic remittance advice (ERA) and eligibility. Medicaids, no surprise, clung to their position as the worst performing payer group. They dominated the lower rungs of the PayerView rankings with Medi-Cal CA coming in dead last out of 132 payers. Unlike past years, national payers secured 3 of the top 5 spots, displacing the regional payers that used to dominate. The top performing payers out of 132 total payers were…drum roll please…

1.            BCBS-RI

2.            Aetna

3.            Humana

4.            UnitedHealthcare

5.            BCBS-MA

And the lowest performing payers were…

128.        Medicaid-TX

129.        Medicaid-PA

130.        Horizon NJ Health

131.        Medicaid-OK

132.        Medi-Cal CA

Aetna stands out of this pack. They made significant inroads and managed to supplant Humana as the best ranked national payer. While Humana actually outperformed Aetna with respect to speed of payment (days in accounts receivable) and a reliable eligibility transaction (Eligibility Accuracy), Aetna’s consistent performance propelled it to the #1 position across multiple PayerView segments such as Major Payers, National Commercial, Midwest Region, etc.

Data suggests, and Aetna performance seems to confirm, that leveraging the full transaction standard suite (e.g. claims, eligibility, ERA, etc.) does translate into gains in performance.  If this is true, what does that say about changes like new clinical quality management programs and new shared savings models like Accountable Care Organizations (ACOs)?

A few questions come to mind:

  • How can we take the lessons learned from the transaction standard set implemented in 2003 and apply it on the clinical front? Keep in mind that we are nearing the 10-year mark since the transaction standards were implemented but we still have a ways to go. athenahealth data suggests that although standards have helped the industry gain a common language, disparities remain. By downloading a copy of our whitepaper you can review our analysis of the ERA Transparency metric to get a sense of how all transactions have not matured equally.
  • What else will we need to do to complement the standard language that the industry is trying to facilitate through incentives for EHRs and performance-based reimbursement? athenahealth data suggests that the standards will only get you so far, and in the clinical space, the standards have a long way to go before reaching true “standard” status.

What are your thoughts? Send in a comment or a question. And while you're thinking about it, see what CEO Jonathan Bush has to say...

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Ideas, insights and analysis to help physicians, medical groups and health systems stay informed and profitable in today's challenging health environment.

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