AMA’s ‘report card’ targets health plans’ performance

The nation’s leading medical society opened up a new front in its confrontation with the health insurance industry Monday with the launch of a campaign to rate HMOs on how quickly and accurately they pay medical claims.

The American Medical Association (AMA), in one of the first actions of its weeklong annual meeting in Chicago, issued the findings of its study on health insurance claims along with resources for physicians seeking to fight insurers over unpaid or underpaid claims.

{mosads}“The goal of the AMA campaign is to hold health insurance companies accountable for making claims processing more cost-effective and transparent, and to educate and empower physicians so they are no longer at the mercy of a chaotic payment system that takes countless hours away from patient care,” said William Dolan, a member of the AMA’s board of trustees.

Physicians often clash with insurance companies over bills, but the two camps also have engaged in fierce battles in Washington, particularly over the Patients’ Bill of Rights in the late 1990s and early 2000s. Though the legislation never made it into law, the efforts by physicians to weaken the health insurers’ position over fee negotiations and claims approvals deepened the rift between the two business sectors.

Claims payments are a sore spot for physicians, who complain about the time and paperwork burdens associated with filing claims under multiple systems with varying sets of rules, especially when those claims are denied and must be contested.

“Physicians want to focus on caring for their patients, not fighting health insurance red tape that may delay, deny or shortchange payments for their services,” Dolan said.

The health insurance industry’s main trade association, America’s Health Insurance Plans (AHIP), responded to the AMA releases by noting that health plans and physicians have a shared responsibility for claims being paid correctly and on time.

“AHIP data indicate that virtually all ‘clean’ claims are processed within 30 days,” said Karen Ignagni, the group’s president and CEO. “In order for claims to be processed as efficiently and promptly as possible, both insurers and physicians need to strive for accuracy and timeliness,” she said, citing a “significant” number of late and incomplete claims from doctors.

Dubbed the “Cure for Claims” campaign, the AMA effort includes a “report card” that rates insurers on several performance criteria, including how often they deny claims, how often they pay the agreed-upon fees for medical services and how quickly they pay claims once they have been filed.

The AMA evaluated claims for more than 5 million electronically billed claims to Medicare and seven large private national insurance companies: Aetna , Anthem Blue Cross Blue Shield , CIGNA , Coventry Health Care , Health Net , Humana and United Healthcare .

Medicare was the most likely to deny any part of a claim, with a 6.9 percent rate. Aetna was a close second at 6.8 percent while the others ranged from 2.7 percent to 4.6 percent.

Coventry Health had the fastest median turnaround between receiving a claim and responding, at four days, according to the AMA. Medicare and CIGNA took a median 14 days; Humana and Aetna, 13 days; Health Net, 11; United Healthcare, 10 and Anthem, seven.

The AMA also advocates for greater transparency in what health insurers pay for services and their reasons for denying claims.

Pricing transparency has gained currency among many health policy experts, who maintain that more information about the actual cost of medical care, the actual charges made by doctors, hospitals and others, and the actual amounts paid by health insurances and government programs can make patients and consumers more aware of healthcare costs. That awareness, in turn, could lead to greater competition between providers on price, which could slow down the rapid growth in healthcare spending.

In its statement, AHIP pointedly argues that improving efficiency is not the sole responsibility of the health insurance industry, noting that physicians do not always follow the most clinically or cost-effective courses of treatment, leading to wasteful spending on healthcare due to a “wide variation in practice, overuse, underuse and misuse of services,” Ignagni said.