Local, State, Federal

Payor Performance Ranked
ACR Members Go to Washington

Payor Performance Ranked

For the third consecutive year, Physicians Practice magazine has joined with athenahealth, of Watertown, Mass, to provide hard data and rankings on payors and their payment performance. In its June 2008 issue, the publication reported on the latest findings of its PayerView analysis, whose goal is to “identify quantitatively where physician-payer relationships are breaking down, measure trends, and work toward improvement,” according to the magazine.

Rather than utilizing anecdotal opinions about payors, PayerView focuses on actual claims data that is taken from athenahealth’s AthenaNet system database. Because athenahealth employs application service provider software to offer physician billing, practice management, and EMR services, it can access useful billing and payment data.

The 2007 roundup included claims performance data from more than 12,000 providers representing more than 30 million charge lines. Seven categories were examined to weigh the payors, who were measured by days in accounts receivable, first pass resolve rate, denial rate, percentage of patient liability, claim denial transparency, percentage of claims requiring medical documentation, and rate of noncompliance with the Correct Coding Initiative (CCI). Each measure accounted for varying percentages of statistical weight, depending on their individual contributions to the overall financial well-being of a practice.

“We didn’t measure how much payers pay,” the report states. “What we’re getting at here is how hard it is to collect what you are owed.”

Aetna improved from last year’s second-place ranking to claim the top spot among national payors in 2007. It boasted the best denial rate among national payors and, by far, the fewest days in accounts receivable. Its 26.86 figure handily beats its nearest competitor, Cigna, by nearly 6 days.

Aetna, which works regularly with athenahealth to improve its PayerView metrics, attributed its low denial rates to the publication of claim rules on its Web site. Paul Marchetti, head of Aetna’s national networks and contracts services, told the magazine that the public rules “explained our bundling and unbundling logic, how we processed claims, what we would deny for. … Transparency is really the bottom line.”

Medicare had a middle-of-the-pack showing among national payors, coming in at fourth place mostly due to public billing rules that comply with CCI edits. TRICARE occupied the last-place ranking, though it believes the report is misleading. “Fourteen percent of TRICARE medical claims for care rendered in the United States during FY 2007 were denied on first pass,” said TRICARE spokesman Austin Camacho to Physicians Practice. “This is consistent with industry denial rates.”

In terms of regional payors, Blue Cross Blue Shield enjoyed the fewest days in accounts receivable and the lowest denial rate in the nation for the second year in a row. On the other hand, Medicaid of New York, with its “complex referral authorization requirements,” original signature requirements on paper claims, and proprietary claims forms, saw the most days in A/R and had the worst first pass resolve rate in the nation.

All in all, the report concludes that consumers should use the information to see where their provider stands in relation to others in the market, as well as to determine whether their own internal processes are creating problems. Moreover, the data can be useful at contracting time.

“Even payers with high reimbursement might not be ‘good’ payers for you if it takes 60 days or painful machinations to get the money from them,” the report concludes. “A quick note pointing out their lackluster performance relative to others might help.”

To view the report online, visit www.athenapayerview.com or go to Physicians Practice’s Web site at www.physicianspractice.com.

ACR Members Go to Washington

More than 360 radiologists visited over 300 House and Senate offices on Capitol Hill on May 21, as part of an American College of Radiology campaign to advocate for passage of a Medicare package that avoids cuts to physician reimbursement and medical imaging.

According to Orrin Marcella, ACR director of congressional affairs, members met with various lawmakers and their staffs to discuss how to avoid the anticipated 10.6% cut to physician reimbursement called for by the Sustainable Growth Rate (SGR) formula. The SGR is scheduled to go into effect on July 1.

Mark Yeh, MD; Jenny Chen, MD; Rep David Dreier (R-Calif); and Mark Alson, MD.

“We viewed it as a huge success,” Marcella said about the ACR’s deployment of radiologists. “Our timing was great, and we feel we were very well received.”

ACR members advocated for a number of different measures, including replacing the looming SGR physician payment cut with 1 month of positive reimbursements. This would “provide enough time for Congress and affected parties to come up with a stable and fair alternative to the flawed SGR system,” Marcella said.

Furthermore, radiologists urged members of Congress not to provide SGR relief through further cuts to medical imaging services, as had resulted from the Deficit Reduction Act. They also asked legislators to address imaging utilization concerns with true utilization policies instead of reimbursement cuts.

“Medicare should require facility accreditation for providers of advanced medical imaging—MR, CT, PET, and nuclear medicine,” Marcella said. “This would establish a standard baseline for patient safety and quality.”

Additionally, Medicare should direct the use of “physician developed imaging Appropriateness Criteria,” he said, which would allow the patient to undergo the most appropriate imaging study.

As of press time, the ACR had expected the Senate Finance Committee to propose a Medicare package on the Senate floor by mid-June. Marcella pointed out that the legislation must pass both the Senate and House before being ultimately sent to the president.

“The politics, however, remain largely unchanged since last year, and there is the possibility for a repeat of last December, where the various sides cannot agree to anything more than a short-term SGR ‘patch’ that contains no new policy,” Marcella said. “This scenario would mean that Medicare legislation to avoid another SGR cut would have to be addressed early on in the next Congress.”