AMA National Health Insurer Report Card

July 18, 2008

The AMA has issued its first report card on health insurers with a focus on determining the timeliness, transparency and accuracy of claims processing by payors.

Perhaps the most revealing statistic from the National Health Insurer Report Card (NHIRC) is that “physicians are spending as much as 14 percent of their total collections to obtain accurate payment for their services,” according to the AMA. Furthermore, the data gathered for the report card revealed that even when physicians submit correctly coded health care claims, payors are still routinely and inappropriately delaying, denying or significantly reducing payments. The AMA hopes physicians and payors will review the NHIRC and work to support efforts to reduce the cost of claims administration to 1 percent of collections.

In addition to Medicare, the first NHIRC looks at the following national commercial health insurers:

  • Aetna
  • Anthem Blue Cross and Blue Shield
  • CIGNA Corp.
  • Coventry Health Care
  • Health Net Inc.
  • Humana Inc.
  • UnitedHealthcare

According to the AMA, the NHIRC uses the following 14 metrics to analyze payors:

1. Payer claim received date disclosed

2. First remittance response time (median days)

3. Electronic remittance advice activity during the data period

4. Allowed amount disclosed

5. Contracted payment rate adherence

6. Contracted fee schedule available on the payor’s Web site

7. Number of contract fee schedule codes allowed per request

8. Availability of payer proprietary code edits

9. Medical payment policies available on the payor’s Web site

10. Percentage of claim lines (i.e., records) reduced by edits

11. Source of claim edits

12. Percentages of claim lines (i.e., records) denied

13. Claim Adjusted Reason Codes given for denials

14. Remark codes given for denials

The data for the NHIRC was obtained from the health insurers’ Web sites and supplemented by a database maintained by National Healthcare Exchange Services, a company located in Sacramento, Calif. It includes more than 5 million services billed on more than 3 million claims between the second half of 2007 and the first quarter of 2008. Claims come from 20 states, more than 7,500 practicing physicians in 18 specialties, and 195 practices.

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