Doctors versus Payers: Round Two

Increasingly, payers throughout the country have been issuing “report cards” on participating physicians. While payers argue that these report cards provide valuable information to “consumers” (i.e., patients), physician groups have loudly opposed these report cards asserting that the grades are based on faulty assumptions and are presented in a misleading manner. This frustration regarding the report cards has resulted in litigation in multiple states brought by individual physicians, physician groups and state regulators.

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Finally, physicians are fighting back.  Earlier this week, the American Medical Association released its 2008 National Health Insurer Report Card.

The AMA’s Report Card provides information regarding key metrics including:

  • Timeliness of adjudication and reimbursement
  • Accuracy of payment
  • Transparency of payers on payer websites and ERAs
  • Denial details

A quick review of the results reveals some interesting details. For instance, the AMA Report Card indicates that CIGNA provides incorrect reimbursement (i.e., the payer’s allowed amount does not equal the contracted payment rate) for almost 33% of the claims it processes. According to the AMA, UHC’s performance was worse, failing to adhere to the contracted payment rate in 38% of the analyzed claims. However, there is good news for physicians who participate with Medicare: Medicare leads the pack in compliance, with a “contracted payment rate adherence percentage” of 98.12%. The AMA Report Card is an important step forward for physicians. Nevertheless, it is important to remember that the conclusions reached in the report are based upon a limited subset of claims data. As time goes on and updated report cards are issued covering a wider swath of data, the AMA Report Card will undoubtedly play an important role in encouraging payers to improve responsiveness and will empower doctors to make wiser business decisions. However, in its present form, many will argue that the 2008 National Health Insurer Report Card suffers from the same ills as the physician report cards issued by the payers.

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