AMA wants physicians to stake a claim for accurate insurer payments this fall
AMA
October 29, 2008
As part of its national campaign to save the health system billions of dollars by improving the accuracy and efficiency of medical claims processing, the American Medical Association (AMA) today announced it has selected November for the first national Heal that Claim Month.
Many physician practices often experience an increase in claim denials from health insurers during the last quarter of the year, making November an ideal time to appeal inappropriately underpaid and denied claims. An estimated 90 percent of claim denials are preventable and 67 percent of denials are recoverable, according to the Advisory Board Company, a Washington-based research organization. Based on those estimates, physicians collectively lose billions of dollars a year of revenue to health insurers.
Heal that Claim Month is part of the AMA’s ongoing Heal the Claims Process campaign, which launched last June with the unveiling of the AMA’s first National Health Insurer Report Card, an objective comparison of the nation’s largest health insurers and their claims processing performance.
http://www.ama-assn.org/ama/pub/category/20209.html
And…
2008 National Health Insurer Report Card
AMA
Contracted payment rate adherence
On what percentage of records does the payer’s allowed amount equal the contracted payment rate?
Aetna – 70.78%
Anthem – 72.14%
CIGNA – 66.23%
Coventry – 86.74%
Health Net – not reported
Humana – 84.20%
UHC – 61.55%
Medicare – 98.12%
http://www.ama-assn.org/ama1/pub/upload/mm/368/reportcard.pdf
And…
Appeal that Claim
AMA
When a physician practice assumes that the reimbursement it receives from health insurers is always accurate, the practice may lose revenue. Even when a practice codes claims correctly, health insurers may still inappropriately deny, delay or significantly reduce payments. By implementing claims auditing processes, you can ensure that health insurers pay your practice appropriately for your physician procedures and services.
Step 1: Determine who will be responsible for auditing health insurer payments
Step 2: Collect recommended health insurer auditing resources
Step 3: Run monthly collection reports
Step 4: Review the health insurer explanation of benefits (EOB)/remittance advice (RA) on each claim identified on the collection report
Step 5: Identify the health insurer basis for the denied, delayed or partially paid claim
Step 6: Gather supporting documentation to corroborate reversal of the health insurer’s determination through the claims appeals process
Step 7: Develop a claim appeal letter and resubmit the claim to the health insurer
Step 8: Maintain a health insurer follow-up log
Step 9: Hold claims processing and review meetings
Step 10: Continue to appeal inappropriately denied, delayed or partially paid claims
Appeal that Claim (65 pages):
http://www.ama-assn.org/ama1/pub/upload/mm/368/appeal-that-claim.pdf
The AMA has selected November as the first national Heal that Claim Month. The problems that this addresses must be fairly significant if they are going to declare a special month to address them; so what are these problems?
The U.S. health care financing system is infamous for its profound administrative waste. Some of it is due to the fragmented system of a great multitude of private payers plus public programs with various rules and regulations which increase the complexity of the billing process. Besides the administrative costs of the insurers, which is typically about 18 percent of their premiums (i.e., medical loss ratio of 82 percent), the administrative burden that this system places on physicians and hospitals consumes about another 12 percent of the insurance premiums.
These numbers refer to the routine of claims preparation and processing. But the 2008 National Health Insurer Report Card demonstrates that the nefarious behavior of the private insurers has compounded the complexity by reimbursing at rates significantly below those that were established in contracts with the physicians.
The private insurers are cheating, and they depend on physicians being overwhelmed by this administrative burden to not get caught in their evil deeds. This goes far beyond the complex routine of private insurance administrative processes. This is racketeering.
In the ultimate of ironies, the AMA has responded with an additional, complex, burdensome administrative process to ferret out the private insurers that cheat (which is all of them!), so that they can demand reimbursement at rates that the insurers contractually agreed to. Understanding the element that they are dealing with, the final step recommended is to continue to assert compliance with these contracts agreed to by these recalcitrant crooks.
So what is the AMA recommendation for reforming this horrendous, highly wasteful system? More of it! They want to expand the market of private health plans and use our tax funds to provide credits for purchasing these plans.
The AMA should take a closer look at their own National Health Insurer Report Card. All of the private insurers are crooks, but our own public insurer, Medicare, has over a 98 percent compliance with contracted rates. Just imagine if Medicare were the only payer. The ease and transparency of the process would likely result in 99.99 percent compliance.
Instead of wasting more time and resources on a Heal that Claim Month, we need to proclaim January 2009 as a New and Improved Medicare for All Month!