Transparency and Disclosure
All health plans must disclose all information necessary to determine the relative financial rights and responsibilities payers and patients prior to the provision of a healthcare service. This includes full, complete transparency of the contract-specific payer fee schedule, payer medical payment policies, reimbursement rules, and other payment reductions. The AMA has developed a National Health Insurer Report Card (NHIRC) as a mechanism to provide physicians and the general public a reliable and defensible source of critical metrics concerning the timeliness, transparency and accuracy of claims processing by health insurers. The 2009 report card expanded the metrics to include an expanded Transparency Survey. NHIRC data demonstrate that significant opportunity exists to increase transparency and disclosure of information necessary to determine patient and payer financial responsibilities. Specifically, the AMA recommends the following actions:
Designate CPT guidelines and conventions as a HIPAA Standard
The AMA recommends that the CPT guidelines and conventions be mandated as the operational guidelines and instructions for the CPT codes. We believe CPT guidelines and conventions should be adopted in addition to the CPT codes to reduce inconsistencies in the recognition and reporting of physician procedures and services. Not adopting the CPT guidelines and conventions undermines administrative simplification and transparency efforts because stakeholders do not have consistent, standard guidelines and conventions for applying CPT.
Implement standard pricing/payment rules
Payment rules should be transparent and applied consistently within and among payers. Further, new or updated payer payment rules along with complete physician-specific fee schedules must be made available on the payer Web sites. Payers should provide physicians with easy online access and the ability to download their complete payment rules and fee schedule so there is no question regarding the accuracy of the application of the payment rules and the actual fee schedule amount. In addition, physicians need sufficient notice of changes and updates to the payment rules and contracted fee schedule from the payer before they take effect. Payers should provide this information in a format that is easy to understand and allows an easy way to update physician practice management systems.
Implement standard claim edits
Standard claim edits would provide a common standard claim processing platform for payers, physicians and patients. A standard claims processing platform would not dictate any payer medical rules, claim review or product benefit level and design. The platform would, however, create a level playing field for all payers, including third-party administrators and self-insured employers, by bringing the competition back to price rather than on the application of additional edits in the health care billing and payment process. Similar to payment rules, payers should provide physicians with easy online access and the ability to download claim edits from their Web sites.
Implement the National Payer Identifier
The AMA urges prioritization and adoption of a National Health Plan Identifier for each payer and other entity involved in the health care billing and payment process. The National Health Plan Identifier should clearly specify: the primary payer responsible for payment, any applicable secondary payer responsible for payment, the payer or other entity holding the contract and associated contractual fee schedule with the physician, and the payer or other entity responsible for administering the patient’s benefits and coverage.
