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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: An Annual Transparent Look at Payer Performance and Medical Billing

by John Voith, Director of Transaction Services

It’s been seven years since our first PayerView report drew attention to the administrative variation across health insurance carriers (as in this 2006 New York Times article.) Today, we are proud to announce our 2013 edition of PayerView, as we continue to report on those payers that perform well for physicians in the world of medical billing… as well those that are not necessarily in tip-top shape.

PayerView has always leveraged insights from athenaNet, our cloud-based infrastructure that currently contains data from more than 40 million patient records. By exploring that data from the year prior, we are able to characterize the ease or difficulty our clients experienced when doing business with each payer.

This leads to our ranking of the health insurance carriers. To do that effectively, we evaluate a variety of metrics that are important for a provider’s success—measurements such as Days in Accounts Receivable (DAR), First-Pass Resolve Rate (FPR), and Provider Collection Burden (PCB). Over the years, we’ve found that payers across the country, national payers as well as regional ones, actually use our PayerView comparative data as a valuable resource to inform their own efforts aimed at improving the provider experience.

So what did we learn?
Here are some key points geared toward the two main PayerView audiences: health care providers and payers:

  • Providers
    • Payer Rankings
      • Humana is ranked as the top payer to do business with, taking the #1 spot away from Blue Cross Blue Shield-Rhode Island, the highest-ranked for 2012. (See full list of PayerView rankings.)
      • Medicaid payers continue to be the most difficult to do business with. This is a potential issue for some providers as many additional Medicaid patients are expected to enter the system in 2014.
    • High-impact Findings
      • In early 2012, nearly all payers suffered from problems with the ANSI 5010 conversion, a reset of the entire health care transaction structure (affecting EDI, ERA, Eligibility, CSI) from the “4010” format to the “5010” format, as required by the federal government. This struggle can be seen in the data, as FPR fell to 90.4% in February, compared to an average of 94.2% for the entire year.
      • PayerView data also shows that athenahealth was able to quickly address ANSI 5010 problems, working with payers on clients’ behalf. By June, with ANSI 5010 in full swing, FPR had returned to nearly 95%.
      • Private payers (commercial payers and ”Blues” plans) increased provider collection burden as patient deductibles continued to rise—making private payers somewhat more difficult to do business with—but the burden rose by a smaller amount than in past years. The trend of growing provider collection burden appears to have eased temporarily, but a more rapid acceleration is expected as new reform measures take effect.
  • Payers
    • New Metrics
      • We introduced three pilot metrics with PayerView 2013, keying in on areas that payers should likely focus on for providers. While these pilot metrics did not impact the overall rankings this year, we expect to include them in next year’s analysis—so we encourage payers to take a careful look. These include:
          – Electronic enrollment efficiency: the ease with which a provider can enroll in electronic transactions.
          – Benefit accuracy: how frequently each payer notifies a provider with accurate information so the provider can collect the right amount from patients.
          – P4P Administrative Burden & Transparency: the ease with which providers can learn about and enroll in Pay-for-Performance (P4P) programs, and can submit P4P performance data.
    • High-impact Findings
      • Electronic enrollment continues to be difficult for providers across most payers, with payers still requiring a staggering 65% of transactions to be conducted by fax or mail.
      • Many payers performed worse than the median 95% benefit accuracy, including six payers that only returned correct co-pay information less than 50 percent of the time.
      • Several payers did not fare well in the area of P4P administrative burden and transparency, with just 17% of payers receiving the highest score and 40% not having any clear P4P program information available for independent physicians.

It’s all about the patients.
Because PayerView provides the industry with this unique and valuable insight year after year, we have an entire team at athenahealth that works in parallel with many major payers to monitor trends and drive continuous change in medical billing processes.

This benefits the provider and payer, yes, but it all ultimately benefits the patient. As caregivers choose to do business with better-performing payers, and payers enact easier processes for physicians, caregivers are able to spend more time getting patients the care they need—instead of responding to rejected claims or faxing paperwork to payers. We don’t want physicians stressing over payments or administrative issues; we want them free to focus on patient care. (For a full analysis of the 2013 PayerView report, join our webinar.)

Read this PayerView story for a providers view on the findings.

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