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:
- Payer claim received date disclosed
- First remittance response time (median days)
- Electronic remittance advice activity during the data
period - Allowed amount disclosed
- Contracted payment rate adherence
- Contracted fee schedule available on the payor’s Web site
- Number of contract fee schedule codes allowed per request
- Availability of payer proprietary code edits
- Medical payment policies available on the payor’s Web
site - Percentage of claim lines (i.e., records) reduced by
edits - Source of claim edits
- Percentages of claim lines (i.e., records) denied
- Claim Adjusted Reason Codes given for denials
- 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.
To read a summary from the AMA about the NHIRC, its findings and the AMA’s
suggestions for improving claims processing, click here
(PDF).
View the National Health Insurer Report Card (complete
metrics – PDF).
View the National Health Insurer Report Card (data
only – PDF).
