The Latest PayerView Rankings: How Well Do Payers Work with Physician Practices?
Late payments...multiple denials... puzzling claim submission rules...and no time to follow up with payers on repeated problems. Sound familiar?
Historically, it’s been a struggle for payers and providers to work efficiently together. Payers believe they are doing all they can to meet providers’ needs, and providers believe they are doing all they can to stay afloat. The industry needs an objective, standardized look at the challenges of payers and providers and how they work together.
The good news is that payers and providers want the system to be better. Making the relationship between payers and practices work is important for the financial well-being of both parties – and the entire health care system.
But until now, it has been almost impossible to steer the health care industry towards a mutually agreeable path forward.
Getting to a solution
It’s time we provided payers with objective insight into the challenges of running a practice, and asked them to improve their own processes based on this information. With the help of athenahealth’s dynamically-managed claims data from thousands of practices and hundreds of payers across the country, we can do just that.
PayerViewSM – an annual project of athenahealth – is the industry’s first quantitative report addressing the fundamental pain points that currently exist between insurers and providers. The idea behind PayerView is to create an industry-wide dialogue on how breakdowns in these relationships can be addressed.
And it’s working.
How does PayerView work?
PayerView is an approach to ranking payers based on how well they worked with athenahealth and our physicians. We avoided anecdotes and impressions and focused on hard data from the physicians and payers with whom we interact. We measured payer performance in financial, administrative and medical policy complexity categories.
Together, these measurements represent athenahealth’s analysis of how easy or difficult it was during the data collection period for athenahealth clients to get paid quickly and accurately on claims submitted to the listed payers.
athenahealth widely publicizes the PayerView rankings (for full results, visit www.athenapayerview.com). We then use PayerView data to collaborate with payers to make improvements in the payer/provider relationship.
What Does PayerView Measure?
To set overall national and regional rankings, we weighted each of seven measures (below), placing a priority on fast, complete payment. When claims submitted to a payer were paid quickly and fully, the payer tended to do well in the overall ranking.
Here are the metrics we measured and the weight assigned to each:
| Financial Performance (57.5% of total score) |
- Days in accounts receivable (DAR) – 25 percent of total score – The number of days it takes a practice to get paid from the date the charge was entered into athenahealth’s system. The calculation is done by divding the average total outstanding A/R by the average daily charge. - First pass resolve rate – 25 percent of the total score – The percent of claims that were successfully resolved on the initial submission – meaning they were either fully paid or determined to be the patient’s responsibility. - Percent patient liability – 7.5 percent of the total score – The percent of billed charges transferred to patient responsibility. This is a proxy for the burden placed on practices to manage patient collections. |
|---|---|
| Administrative Performance (35.0% of total score) |
- Denial rate – 20 percent of the total score – The percent of claims (both pended and denied) that required the practice to perform back-end rework. - Claim denial transparency – 7.5 percent of the total score – The percent of denied claims that were paid with just one resubmission. The aim is to measure how clear the payer is on the reason for the denial. - Percent of claims requiring medical documentation – 7.5 percent of the total score – The percent of claims that required the practice to attach medical documentation to justify payment. |
| Medical Policy Complexity (7.5% of total score) | - Percent non-compliance with the Correct Coding Initiative (CCI) – 7.5 percent of the total score – The percent of claims not receiving payment as a result of a payer’s departure from national coding standards. |
PayerView doesn’t measure how much payers pay. PayerView’s goal is to quantify the challenges practices face in collecting for their services. For further details on these metrics, please visit www.athenapayerview.com.
The Latest Rankings: A Snapshot
athenahealth 2008 PayerView Results
For full results, including regional rankings, please visit www.athenapayerview.com.
How PayerView drives industry change
PayerView gives us a framework to systematically address gaps that occur in the payer/provider relationship. After each PayerView release, we connect with payers to create an agenda based on opportunities identified in the PayerView index.
In fact, since the launch of PayerView in June 2006, some payers have developed teams dedicated to working with athenahealth to improve efficiencies. Most payers have steadily improved on some measures, increasing their overall rank and making it easier for providers to do business with them. Provider organizations, the national media, and payers now look to PayerView as the best guideline of its kind for streamlining costs.
Here are a few examples of how PayerView has enhanced payer/provider effectiveness.
Reduce unnecessary expense. Using PayerView data, athenahealth identified changes that certain payers could make with little effort but that would have a significant impact on both payers’ and providers’ costs. For example, athenahealth works with payers to understand and identify denial trends. Eliminating recurring denials streamlines the claim submission process and improves the bottom line of both parties.
Optimize transactions. For payers that can process electronic submissions of eligibility and claims status information, athenahealth has turned to more targeted improvements. For example, with some payers, athenahealth is working to enrich the content of eligibility transactions to help prevent denials.
Reduce days in accounts receivable (DAR). athenahealth is working to understand the drivers of payment cycle time and determine if there are opportunities to reduce DAR – on both the payer and the provider side. For example, athenahealth executed an aggressive plan to make ERA and electronic funds transfer (EFT) available to its entire provider base. This has helped to eliminate days from the payment cycle as providers spend less time on the phone with payers. They instead get claim advice and payment without delay online.
Create targeted opportunities for under-performers. For payers that have consistently ranked lowest and have been slowest to improve, athenahealth has developed focused plans for improvement. For these payers, athenahealth pinpoints areas where payers lag behind their peers. athenahealth is also able to identify why poor DAR or denial rates, for example, might occur. In collaboration with the payer, athenahealth develops specific, actionable recommendations for improving the issue. And together, athenahealth and the payer track progress towards goals.
How providers benefit from PayerView rankings
Let’s face it – providers enjoy seeing payers on the score board. But besides validation for their struggles to get paid, the rankings offer practices tangible opportunities for improving workflow and profitability.
How?
Payer improvements for all providers. Whether or not you’re an athenahealth client, your practice benefits from PayerView. Whenever we help one of your payers improve its DAR or first pass resolve rate, your practice will see the improvements (as long as your practice has systems in place to support the improvement).
Providers get leverage in payer negotiations. Strategically, PayerView metrics offer practices a standard “language” to use when working with their own payers. In essence, PayerView metrics can become service standards for providers and payers to use when resolving issues or renegotiating contracts.
Providers get better control over practice performance. On a day-to-day basis, PayerView metrics give the practice a set of seven variables to measure and track. Knowing where your own practice falls on these metrics – from how long it takes to get paid to how much back-end-work the practice takes responsibility for – can help the practice see opportunities for improving workflow, getting paid faster, and releasing staff from the administrative burdens of claims follow-up. And that translates into better profitability and more time to pursue strategic activities.
What you can do now with PayerView
Check the latest PayerView rankings to see where your payers fall in our ranking system. Keep in mind the rankings are based on athenahealth clients’ experience with these payers – and not the average practice. Our practices use athenahealth’s centrally-hosted electronic medical record (EMR), billing and practice management solution – and have access to continually updated payer rules during all billing transactions.
Determine where your practice falls in relation to the payer rankings. Are you experiencing even longer DAR from payers than is reflected here? A higher denial rate? A worse first pass resolve rate?
If you can’t easily determine where your practice falls in relation to the PayerView data, you may need better tools for transparency into your own practice performance.
If you know where you stand, figure out where your practice can improve. For more guidance on how to do this using the seven PayerView measures, download our in-depth guide to the PayerView rankings here.