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AMA Launches Campaign to Cut Waste From Chaotic Insurance Claims Process, Unveils New Health Insurer Report Card
Date:6/16/2008

national commercial health insurers: Aetna, Anthem Blue Cross Blue Shield, CIGNA, Coventry Health Care, Health Net, Humana and United Healthcare.

Key findings include:

-- Denials. There is wide variation in how often health insurers pay

nothing in response to a physician claim (from less than 3 percent to

nearly 7 percent), and in how they explain the reason for the denial.

There was no consistency in the application of codes used to explain the

denials, making it extremely expensive for physician practices to

determine how to respond.

-- Contracted payment rate adherence. Health insurers reported to

physicians the correct contracted payment rate only 62 to 87 percent of

the time. Additional analysis will be necessary to determine how often

these errors were tied to inaccurate payment. When health insurers

report an amount that does not adhere to the contracted rate, it adds

additional, unnecessary costs to the physician practice to evaluate the

inconsistency.

-- Transparency of fees and payment policies. More than half of the health

insurers do not provide physicians with the transparency necessary for

an efficient claims processing system.

-- Compliance with generally accepted pricing rules. There is extremely

wide variation among payers as to how often they apply computer

generated edits to reduce payments (from a low of less than .5 percent

to a high of over 9 percent). Payers also varied on how often they use

proprietary rather than public edits to reduce payments (ranging from

zero to as high as nearly 72 percent). The use of undisclosed

proprietary edits inhibits the flow of transparent information to

physicians, adding additional administrative costs to reconcile claims.

-- Payment timeliness. Prompt pay
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SOURCE American Medical Association
Copyright©2008 PR Newswire.
All rights reserved

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