Study Looks At Seven Largest Health Insurers' Payment And Denial Of Claims, USA

Main Category: Health Insurance / Medical Insurance
Article Date: 26 May 2006 - 6:00 PDT

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Insurance claims-processing company Athenahealth on Thursday released a survey detailing the speed and efficiency of payments to doctors from the nation's seven largest health insurers, the New York Times reports. About 7,000 doctors in 31 states are Athenahealth clients, representing about 2% of active doctors nationwide. The survey sample is "not statistically valid, ... [b]ut in any given market [Athenahealth] generally ha[s] a relatively good range of medical specialties," Nancy Brown, Athenahealth's senior vice president for clinical service development, said. According to the survey, Humana's payment practices ranked best overall, based on a variety of categories. Medicare was second best overall, and WellPoint ranked last. Humana on average made payments 29 days after medical services were provided, ranking first, while Champus/Tricare took 41.4 days on average to make payments, ranking last. In the category of the percentage of claims paid within 90 days without changes, Medicare was first, with 92%, while Champus/Tricare's 85.1% ranked last. Humana and Aetna each had the lowest percentage of lost claims, at 0.2%. Cigna reported lost claims 1.3% of the time, the highest percentage in the survey. The survey will be posted on a new Web site, athenapayerview.com, and revised every three months.

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WellPoint spokesperson James Kappel said the survey has "absolutely no statistical significance." Kappel said the number of WellPoint claims in the survey were "very small compared with the total number that WellPoint alone processes." However, "[m]ost of the other national insurers in the report, ... regardless of how they fared, acknowledged the survey as a unique and potentially useful snapshot," the Times reports. Mark Lindsay, a spokesperson for UnitedHealth, said, "We are pleased that Athenahealth had fairly positive readings of our provider payment practices, but we do not believe the study is truly representative of our business." Herb Kuhn, director of CMS' Center for Medicare Management, said the survey was "critical" to insurers "in managing their competition." Cigna spokesperson Wendell Potter said that the survey "provides some common metrics that will be useful for future benchmarking," adding, "Making improvements for all payers is likely to be a work in progress for some time to come." California Medical Association CEO Jack Lewin said payment tardiness or refusal to pay increases physicians' overhead costs by as much as 15% to 20%. Phil Pead, CEO of Per Se Technologies, a claims-processing company with services paid for by both physicians and insurers, said, "About 40% of denials occur because of incorrect information [from physicians] -- the wrong insurance card or address or other information" (Freudenheim, New York Times, 5/25).

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