American Medical News
By — Posted July 1, 2013
Chicago A change to the American Medical Association's annual National Insurer Report Card reflects a growing burden physicians face when it comes to getting paid — collecting the patient portion.
Since its launch in 2008, the AMA's annual report card has revealed the physicians' burdens when it comes to getting paid by insurers. In the 2013 report, released during the AMA Annual Meeting in June, analysts calculated the percentage of the medical bill for which patients are responsible for paying through co-payments, deductibles and coinsurance and found that it accounts for nearly one-quarter of medical bills overall. Humana had the lowest patient responsibility at 15%, and Health Care Service Corp. had the highest at 29.2%.
The report was based on claims data from services submitted in February and March from Aetna, Anthem Blue Cross Blue Shield, Cigna, HCSC, Humana, Regence, UnitedHealthcare and Medicare.
“For physicians used to getting payments exclusively from insurers, increased patient cost responsibility poses new challenges,” said Mark Rieger, vice president of payment and reimbursement strategy for National Healthcare Exchange Services, a compliance and denial management solutions provider in Sacramento, Calif., that supplied most of the data used in the analysis.
“Physicians are basically not very good at collecting the patient responsibility. And this is a problem, overall, because as the burden shifts more to patients, more of your revenue is at risk,” Rieger said.
Because this was the first year the report looked at the patient portion, it did not provide historical context for the rise in patient responsibility. But a November 2012 Kaiser Family Foundation report showed that the percentage of workers covered by a plan that includes a deductible rose from 52% in 2006 to 72% in 2012. Those who were in such a plan saw deductibles rise from an estimated average of $584 to $1,097 during the same period.
The problem for physicians, says the AMA, is that they don't always know what the patient portion is at the time of care, making it difficult to collect during the visit. That's when patients are most likely to pay, and it also saves the physicians the cost of chasing down bills.
“Physicians want to provide patients with their individual out-of-pocket costs but must work through a maze of complex insurer rules to find useful information,” said AMA Board of Trustees Member Barbara L. McAneny, MD. “The AMA is calling on insurers to provide physicians with better tools that can automatically determine a patient's payment responsibility prior to treatment.”
The patient portion piece was just one of the many areas of claims adjudication that could benefit from streamlining technology, the report card found. The electronic submission of claims, for example, could reduce the amount of time for claims to be received by insurers.
Health plans said it also falls to doctors to ensure that their systems are ready for faster claims adjudication.
“Health plans and providers share the responsibility of improving the accuracy and efficiency of claims payment. Health plans are doing their part to streamline health care administration to reduce paperwork, improve efficiency and bring down costs,” said Robert Zirkelbach, spokesman for America's Health Insurance Plans, the trade group representing health plans. “At the same time, more work needs to be done to increase electronic submission of claims and to reduce the number of claims submitted to health plans that are duplicative, inaccurate or delayed.”
For example, Zirkelbach pointed to a February AHIP survey that found 16% of electronic claims and 54% of paper claims were received from a physician or hospital more than 30 days after the service date.
Along with the annual report card, the AMA also launched its Administrative Burden Index. It examined the claims that required reworking and calculated a monetary amount of each reworked claim, per each evaluated health plan. A five-star rating system also was designed to highlight areas that need focus.
The index found that HCSC had the highest cost associated with the reworking of claims at $3.32 per claim. Cigna had the lowest at $1.25 per claim.
A typical physician practice will lose $14,600 each year on claims reworked to address insurer denials, said Frank Cohen, senior analyst for Frank Cohen Group, a data analytics firm in Clearwater, Fla., that helped create the report card and the burdens index.
In an emailed statement to American Medical News, HCSC spokesman Greg Thompson said his company, which runs nonprofit BlueCross BlueShield plans in Illinois, New Mexico, Oklahoma and Texas, conducts quality reviews and audits regularly to evaluate and monitor performance. It also is investing in technology and encouraging doctors to file more claims electronically.
“According to our record, we process claims accurately more than 99% of the time,” Thompson said. He said that although the company is proud of the work it has done evaluating and improving claims process efficiencies, “we welcome the AMA and others to reduce the administrative burdens and improve efficiencies in our health care system.”
Thompson said the company was reviewing the report card and the index, and did not have reaction to specific findings.