The 2011 edition of the National Health Insurer Report Cards were recently released and illustrated some disturbing trends.
In case your not familiar with the NHIRC, it’s the 4th annual report sponsored by the AMA looking into financial waste, timeliness and accuracy of claims due to common insurance payer tactics. This year’s segment analyzed claims data from a randomized sampling of over 2.4 million claims. (You can get the full version of the NHIRC here).
Many of the big payers are represented in the report cards – Blue Cross, Blue Shield, Anthem, Aetna, Cigna, United HealthCare and Medicare.
From the findings, it’s likely one or more of these payers are causing you trouble (whether you realize it or not). The report cards allow a glimpse at who is notorious for paying claims late, requiring mounds of paperwork, using underhanded tricks to under-pay contracted fee rates when you’re not looking and more.
Don’t be a victim! Here’s the Executive Summary of what the NHIRC found out:
HOOP JUMPING REQUIREMENTS. For the first time the report card measured how frequently claims included information on insurers requiring physicians to ask permission before performing a treatment or service. In other words, the report card measured how many hoops payers require you to jump through in order to get paid. Obviously, more paperwork means more hassles, less fun and ultimately lower profits since none of us are paid for it. CIGNA was the worst of the worst here with more than six percent of claims needing additional requirements to get paid. Trailing closely behind were United Health Care (4.92%) and Humana (5.2%).
PAYMENT TIMELINESS. It’s no secret that time is money – both for us as chiropractors and for the insurers who hang on to our money as long as possible. Among the worst here was Regence — a western subsidiary of Blue Cross, Blue Shield – who averaged a 15 day response time and only paid 55% of eligible claims within a 15 day time period (as compared to the best payers who responded within 6 days and paid 99.98% of eligible claims within 15 days. Other bad boys: Medicare and Aetna both had slow response times (14 day avg) but at least they still paid over 99% of eligible claims within 15 days. Incidentally, Aetna also ranked among the highest (worst) for $0 claim lines; in other words, they might register a paid claim within 15 days, but the payment might be $0!
FEE SCHEDULE SHENANIGANS. It’s bad enough that our contracted rates are so low. What’s worse is when a payer shortchanges you on the contracted rate as well, paying you even less than you agreed to. Sound shady? It is – and it happens all the time. And the payers hope you don’t notice. Among the worst offenders of this slight of hand trick were Anthem (for the second year in a row) whose reimbursements only matched their contracted rate a mere 62% of the time (yes, that means the other 38% of the time they stole your money!) and a three-way tie for second place between Aetna, Cigna and Regence BCBS – all of whom averaged paying what their contracted rate about 86% of the time.
STATE BIAS. Anyone ripped off is certainly justified in being upset. Some states, however, seem to get more of their fare share of fee schedule shenanigans. Case in point, contracted rates matched reimbursements the LEAST in Iowa (United Health Care only paid Iowa docs the correct rate 58% of the time); Kentucky docs were only paid their contracted rate 72% of the time by Aetna AND Humana; and Wisconsin holds the record for the most abused with Anthem only paying correctly 49% of the time!
RULE CHANGING RIP-OFFS. In many respects, changing rules, CPT requirements and claim edits are what keep coders in business. After all, if the codes or the rules on how to use them never change, eventually most docs would be able to master the insurance reimbursements. Unfortunately, that’s not the case, at least in the last 10 years. What’s worse is the fact that payers now release new “edits” with alarming frequency that subtly change how CPT codes are to be used or create slight nuances in how the rules should be interpreted for the usage of these codes in their policies. The worst offender in this category is Medicare who out-trumps them all with a whopping 2,224,145 policy edits. Just try and see if you can keep up with that many changes! A distant second and third were Aetna with 223,000 edits and United HealthCare with 253,000 edits – a far cry from Medicare’s maze of confusion, but still a whole lot more changes than anyone could possibly absorb and keep track of!
UNDISCLOSED CLAIM EDITS. Constant rule changing is certainly bad news, but the really, really bad news is when a payer releases edits without anyone even noticing. Of course, you can’t be expected to play by the rules if you don’t even know what they are – and that’s the new game in town. These are known as “undisclosed” claims edits and yes, “undisclosed” means they changed the rules but failed to notify anyone, namely YOU. The worst players at this dirty game of pool? Regence BCBS topped the list with 10% of claims reduced to $0 payable thanks to “undisclosed” claim edits. Not far behind were Aetna (8.5%) and United Healthcare (7%) who also saved a significant chunk of change by making it nearly impossible for you to get paid by their everchanging rules.
DENIAL DISASTERS. Face it, everyone hates denials. Some are our own fault. But when denials are a yet another profit-increasing strategy wielded by payers, it gets plain frustrating. Here’s the good news: over the last 4 years (since the inception of the health insurance report cards) the overall denial rate has improved for most payers. In other words, they are denying claims less often — although if you note all the above tricks, you may want still want to hold onto any actual praise. Still missing the boat? Anthem breaks yet another record for four years in the running as the payer that issues the MOST claim denials.
SUMMARY OF THE SUMMARY
Overall, it’s hard to pick one winner or loser in these report cards. According to the AMA, an average of 19% of all claims were processed in error (intentionally or unintentionally was not measured). This is totally unacceptable and represents a whopping $17 billion waste in unnecessary administrative and health care costs.
So, what are you to do with all this information?
Certainly, some of these figures are more than you or I can handle alone. And by publishing this blog I am also certain that I will be forever banned from receiving a “Seasons Greetings” card from any of these payers. In fact, I may do well to watch my back after helping expose their dirt.
But I also am willing to risk my hide because I know that there are many good chiropractors who are literally pulling their hair out, wondering if they are going mad, paranoid, or just plain nutty over some of these very issues. If you are one of these DC’s, yes, your frustrations are real. Pay attention. You are not playing the “insurance game” – this is business. This is your livelihood and your patients’ hard-earned money at stake as well. If you don’t know what you’re doing, why you are losing or how much you are missing out on, get help! (A good place to start would be my Practice Analysis Questionnaire Send it in for a no cost, no obligation look at how things can be improved in your situation.)
These things are not only happening to you, they are happening to your colleagues (whether they notice or not) and they are even happening to MD’s as well. Insurance companies don’t hate chiropractors, they love profits. Hopefully, this post has enlightened some of you to be aware of some of the dirty tricks they use to increase their bottom line, at the expense of yours.
I also hope I can continue to keep faithful to our profession by fighting the good fight, as there is much work to be done!
Unless they get me first – ‘Til next time!