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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.

2014 PayerView Report: The Good, the Bad and the Ugly in Health Care Reimbursement

by Kim Williams, Executive Director of Payer Intelligence

It’s that time of year when athenahealth shines a spotlight on provider-payer relationships, releasing the specifics in our annual PayerView Report. By analyzing data across our national, cloud-based network, which to date includes more than 52,000 health care providers, we’ve ranked commercial and government health insurers according to a series of specific measures covering financial, administrative, and transactional performance. Our goal is to help make the health care reimbursement process as transparent as possible, so that practices can respond to industry trends and providers can gain insight into the world of payers.

Despite ever-changing industry mandates and the challenges of health care reform, there was a lot of positive momentum that providers can keep top of mind when evaluating how to work with Payers in 2014.

  • For the second year in a row, Humana ranked #1 in overall performance. Out of 148 total payers in our analysis, Humana led in six categories: all payers, commercial, major, and three geographic categories. Overall, Humana is the easiest, most efficient and transparent payer to deal with when it comes to medical reimbursement.
  • Blues have the lowest DAR. Blue Cross Blue Shield (“Blues”) state specific plans reimburse providers the fastest, with an average of three fewer Days in Accounts Receivable (DAR) compared to all other payers. On this transactional measure, Blues represent 20 of the top 25 performers, displacing major commercial payers' historical position as the leading category. This is good news considering their prominence in the marketplace.

Vendor-payer collaboration can improve performance. I believe Cigna said it best when it comes to the value of working together to help drive provider performance: “We partnered with athenahealth in 2013 on multiple claim and eService initiatives to improve transparency and efficiency. This collaborative effort resulted in significant process improvements that made it easier for health care professionals to do business with us, and it boosted Cigna’s rankings on the 2014 PayerView Scorecard, moving us to the number two spot among major payers overall,” said Julie Vayer, Vice President for Cigna Total Health and Network Operations. This year, we were also able to work with many notable payers on mutually beneficial opportunities such as call reduction, ICD-10 Testing, and health reform solutions.

Unfortunately, not all payers are as collaborative. Medicaid is an important part of many providers’ lives. Serving the Medicaid population is the right thing to do, but it is rife with challenges. Some state Medicaids are high performers in their category, while many remain among the slowest paying, least transparent payers overall. Working with Medicaid is anything but easy. (Note: To be clear, we are not referring to what they do for patients — this is only about tracking how easy or difficult it is for providers to work with them.) As enrollment is expected to jump from 56 million in 2013 to 85 million by 2021, those who learn to work most efficiently with the Medicaid’s common issues will be more successful.

  • Slowest to pay out. Compared with other payers, Medicaid is consistently the slowest in days in accounts receivable (DAR) between charges submitted and payment received.
  • Highest denial rates, least transparent. When claims get denied, it’s important for payers to return them with Electronic Remittance Advice (ERA), including clear next steps and denial explanation. Unfortunately, Medicaid has the highest denial rate — and also the lowest ERA transparency.

Medicaid rankings signal that providers need to get help with revenue cycle, denial and enrollment services. PayerView helps providers plan around slow-pay out, budgeting and low transparency.

(View our “What are the Risks to Providers” infographic for supporting Medicaid data.)

By revealing the good and bad, clear winners and losers of PayerView come to light. What is less visible is the increasing complexity (the ugly) that distracts providers from being able to do the right thing. One of the most complicated changes is occurring at the payer-provider level: The shift to value-based reimbursement. As more providers shift towards value-based care, they need to know the strengths and weaknesses of payers in order to navigate through change. PayerView may need to shift too, assessing new metrics to evaluate payers’ transparency, efficiency, and administrative burden in relation to value-based reimbursement.

Although ugly, we have seen some wins in reducing administrative waste from the health care system. We hope to continue to work collaboratively with payers while also creating enough disruption to prompt improvement. As we continue to innovate PayerView, we hope it will continue to serve providers as a trustworthy source, helping them navigate change and better understand the world of payers.

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