What You Need to Know About Your Health Insurer Before Your Next Doctor's Visit


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The American Medical Association’s public release last week of its first health insurance report card did not sit well with insurance companies -- and for good reason. The exposure of these companies’ inefficiencies in processing claims, and the resultant extra costs, isn’t exactly great for PR.

The AMA’s aim in launching its Cure for Claims campaign is to reduce administrative costs and assure the accuracy of insurance payments for doctors’ services. The campaign’s ultimate goal is to restore the efficiency of processing medical claims.

For its first National Health Insurer Report Card, the AMA examined Medicare, and seven other health insurance providers -- Aetna (AET), Humana (HUM), UnitedHealthcare (UNH), Coventry Health Care (CVH), CIGNA (CI), Health Net (HNT) and Anthem Blue Cross and Blue Shield -- rating each on the punctuality and accuracy of its claims process. The AMA looked at several metrics, including timeliness, accuracy, fee- and payment-policy transparency and denials.

The report card was released as part of a broader statement that insurers need to take corrective measures to improve a system meant to make patients, not payments, a doctor’s first priority.
The results paint a bleak situation. Among the key findings were inconsistencies in the application of codes used to explain denied payments, inaccuracies in the reporting of contracted payment rates (which plague physicians with additional costs needed to evaluate the variable figures), and the use of undisclosed proprietary edits by insurance companies, inhibiting the transparency of information relayed to physicians, according to the AMA’s report. In fact, physicians currently spend 14% of their total revenue just to receive their proper earnings, AMA board member Dr. William Dolan told the AP.
“We are hoping to get rid of ambiguity and create a more uniform system,” says AMA media spokesman Robert Mills. Mills describes the direct and indirect impact of claims processing on patients. Patients are indirectly impacted by the substantial amount of money wasted on claims that can be saved and used to improve care, allowing physicians to spend more time with patients and evade red tape. “By creating an efficient system, we will be able to lower healthcare costs and reduce insurance premiums,” Mills says.

The direct impact on patients is that, due to the ambiguity of health insurance, it’s virtually impossible for physicians to instruct patients about their financial responsibilities. “If we get rid of ambiguity and create more transparency, then we can create a more open system -- like Medicare,” says Mills.

According to him, a uniform system is in place for reporting claims but not for paying them. Insurance companies invent internal codes, or proprietary codes, generally inaccessible to physicians, that dictate a company’s approach to processing claims. “If the claim gets underpaid, why should physicians and patients be penalized?” Mills asks. The AMA want to get rid of proprietary edits and go with a public system that benefits patients by conserving doctors’ time for what matters most -- providing care.

Dolan informed the AP that the Cure for Claims campaign intends “to hold health insurance companies accountable for making claims processing more cost-effective and transparent, and to educate and empower physicians.” Mark Rieger, CEO of National Healthcare Exchange Services, concurs.

“I think the most important thing we are trying to accomplish is raising awareness and starting a dialogue,” he says. The long-term goal is to reduce the cost of doing business between all parties -- insurance companies, doctors and, most importantly, patients. AMA representatives indicated that both business leaders and health policy makers want to cut around $210 billion annually in wasted administrative claims processing costs.

Rieger points out that because there are around 50,000 physicians’ organizations, doctors struggle to organize themselves in a way that enables them to collectively present themselves meaningfully. “From the doctor’s point of view, what we are interested in are transparency, accuracy and efficiency,” he says. “Those things are not only good for doctors but for patients.”

Besides encouraging dialogue, the Cure for Claims campaign wants to empower physicians and provide them with tools to “prepare, track and appeal claims when something is either denied or shortchanged,” Mills says. The AMA created the Practical Management Center to help physicians secure these tools.

This health report card is an important step in improving the health care system. With the release of such valuable information, you may find your next visit to the doctor less burdensome on the wallet.

To see how your health insurer stacks up, check out the National Health Insurer Report Card at the AMA’s Web site.

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