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Health plans process almost 20% of claims incorrectly, and it's getting worse


If it seems like it?s harder than ever to get proper payment, it?s not just your imagination. According to the American Medical Association (AMA), health plans make errors in nearly 1 out of 5 claims. Electronic data interchange may help a little.

If it seems harder than ever to get proper payment, it’s not just your imagination.

According to the American Medical Association (AMA), health plans make errors in nearly 1 out of 5 claims. The 2011 AMA National Health Insurer Report Card shows that 3.6 million more commercial claims had processing errors than last year, representing an increase of 2%.

“An inefficient and unpredictable claims system adds substantial cost to the health care system, estimated as much as $210 billion annually,” says Barbara McAneny, MD, an AMA board member.

Navigating health plan claims and approval processes cost physicians dearly in both time and money. “Physicians spend the equivalent of 3 weeks annually on health plan red tape,” says McAneny, and “divert as much as 14% of their gross revenue to insure accurate and sure payments for their services.”

Almost 23% of claims are not paid at all. “In every case, the liability shifts to the physician to determine both the validity of the payment and rework necessary to settle the charge,” says Mark Rieger, chief executive officer of National Healthcare Exchange Services (NHXS), one of the consultants assisting the AMA in developing the 2011 report card.

“Physician practices manually review each denial,” adds Rieger. “According to industry estimates, as much as 50% of physician revenue cycle costs are related to reworking denials.”

While expensive and time-consuming, reworking denials makes good business sense. Over the past 4 years, several insurers have made substantial improvements in paying claims at their contracted rates, but only United Healthcare has a match rate above 90%. At the low end, Anthem Blue Cross Blue Shield’s overall match rate is just 62%-and it drops to less than 54% for the evaluation and management codes that dominate claims submitted by primary care physicians. 

To improve the speed and accuracy of your payments, McAneny recommends verifying eligibility, submitting claims, and accepting funds transfers electronically.

And Rieger notes that because the data in the latest report card comes from physician groups that have adopted best practices for electronic data interchange and contract compliance, the reported results may be better than those obtained by practices still using manual claims submission or auditing methods.

Go back to the current issue of eConsult.

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