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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.

Tracking Payer Performance: The 2015 PayerView Report

by Kim Williams, Executive Director of Payer Intelligence

Today, we announced findings from our 10th annual athenahealth PayerView Report. This is our ranking of commercial and government health plans based on nine specific measures focusing on financial, administrative and transactional performance. These metrics reflect how well each payer works with health care providers. The data set for this year’s study is our biggest yet: we analyzed 2014 calendar year data from more than 59,000 providers across all 50 states, covering 166 payers and over $28.5 billion in charges. Compared to our first PayerView Report in 2006, the number of providers evaluated has increased seven fold!

So, which payers made it to this year’s Top 10 Performers list? Which simplified claims processing, and had the greatest transaction accuracy, efficiency and clarity? Here are the headlines:

  • HealthPartners, a small non-profit in Minnesota, ranked #1 in 2015 PayerView, jumping from #2 in 2014.
  • Blue Cross Blue Shield (“Blues”) state-specific plans dominated the top 10
  • Humana is the only major payer in the Top 10 Performers, coming in at #3

(See the 2015 PayerView Top 10 Performers and other insights now.)

The mix of payers within this year’s Top 10 Performers certainly reflects a changing payer landscape: Group Health Cooperative, Health Partners, and Maryland MCO all succeed in small markets, and represent health plans where the traditional lines between payer and provider are blurred. Of these, Maryland Physician Care MCO, a provider sponsored organization offering a Medicaid-managed product, was the biggest surprise, ranking #5 in its PayerView debut. Maryland Physician Care and other provider-owned payers now meet strict PayerView inclusion criteria such as sufficient claim volume and a representative client mix – as these type of health plans become more prevalent, it will be interesting to see if more start landing at the top of the pack.

In addition to gaining insight into the top performing payers, the 2015 PayerView Report also reveals a number of trends we’re seeing across the payer landscape. 

How did payers perform given market change?

  • Overall solid payer performance continues despite market turbulence
    • Payers have done a good job holding their ground despite major changes related to the rollout of the Affordable Care Act (ACA).
    • Health plans concerned with operating losses due to ACA-related costs (taxes, fees, participation in the state and federal insurance exchanges) performed better than expected.

  • Medicaid expansion states performed better than non-expansion states;
    • The swell of Medicaid enrollees did not result in performance problems for the provider.
    • Expansion states did better because they performed especially well in metrics such as benefit reliability.  

  • Blues and commercial payers offering health plans in the exchange performed better than non-exchange carriers. Payers that participated in the exchanges saw improvement in days in accounts receivable, denial rate, benefit reliability and eligibility accuracy. 

Despite performance, do providers trust their payers?

This year, as part of our look at payers, we teamed with ReviveHealth to understand the level of trust providers have in their payers. Despite the strong overall operational performance of payers, an annual payer survey and trust index from ReviveHealth, which measures the behavioral reliability, honesty, and fairness of payers as perceived by hospitals and health systems, shows provider trust of payers remains generally low. However, Cigna and Aetna ranked high in both reports, while UnitedHealthcare continues its year-over-year decline.

(View State of the Payer infographic for more details (PDF).)

Future industry shifts require attention to payer performance today

As the industry continues its rapid transition to value-based reimbursement, and payers need to succeed with more complex payment models, providers should take payers’ performance into consideration. With competition very tight across a number of PayerView metrics, payers can differentiate themselves and their performance by working with providers to deliver new information needed for these new models.

Additionally, with the ICD-10 transition likely to occur this October, we may very well see a major impact on payer metrics in our 2016 report. Since quality and consistency of payer testing varies, payer contingency plans and communication need to remain stronger than ever. A recent athenahealth survey gives us a snapshot of payer readiness for ICD-10:

  • 93% of payers in outreach
  • 90% of payers testing for ICD-10
  • 84% of payers provided contact for ICD-10

As providers continue to take part in risk-sharing models and navigate mandated changes such as ICD-10, having payer partners that can navigate change and perform well is imperative. We continue to evolve and refine PayerView, ensuring that the analysis reflects how well payers respond to providers’ changing needs, and which payers are ahead of the curve. As we continue to innovate PayerView, we hope it will continue to serve providers as a trustworthy source, helping them navigate change. 

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Cloudview Blog

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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Submitted by Donna Masucci RN - Wednesday, May 20, 2015

I have no idea how Tufts Health Plan made it as #1 for their Medicaid product. I have been having horrendous issues with Tufts Network Health Medicaid Product in MA since July 2014. I would love to share my numerous issues with athenahealth that we are having with this payer.

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