AMA White Papers
AMA white papers on administrative simplification issues are developed and published to raise the awareness and priority of the critical costly manual processes endured by the physician practice that must be automated by all participants in the claims revenue cycle in order for all parties to realize reduced expense and increased administrative relief.
- Standardization of a code-editing system
- Standardization of prior authorization process for medical services
- Standardization of EFT transaction and process
- Standardization of the claims process
- Standardizing CPT® codes, guidelines and conventions
- Administrative simplification
Billions of dollars in cost savings for physicians, payers and the health care industry as a whole can be realized by adopting a standard code-edit set. Elimination of the multiplicity of payer-specific edits would make it much easier to move to real-time adjudication of claims. A standard code-edit set would also enable the development of more robust upfront "claim scrubbers" that would eliminate "unclean" claim submission. Finally, such a code-edit standard would eliminate appeals based on the confusion as to whether a code-edit was properly applied to a claim. Therefore, the AMA calls on all stakeholders to stand behind the development of a standard code-editing system in its newly-released white paper, "Standardization of a code-editing system."
Since 2009, the AMA—along with the AMA Practice Management Federation Staff Advisory Steering Committee and the Prior Authorization (Prior Notification) Medical Services Workgroup—has been working to identify areas related to the prior authorization process for medical services that can be streamlined. The AMA took another step toward reaching that goal through the development of the white paper, "Standardization of prior authorization process for medical services white paper." This white paper outlines the costs and workflow inefficiencies of the current process required of physicians trying to obtain prior authorizations from payers, as well as efforts to streamline the process. Standardization and streamlining will decrease manual processes for securing prior authorizations, reduce the associated costs for both payers and physicians, and improve patients’ overall experience.
Because of the significant savings of time and revenue that can be achieved by physicians through automation of the claims process, the AMA diligently advocates for continued administrative simplification. Today, the prior authorization process is all to often manual, time-intensive and confusing for all stakeholders. The AMA believes that the best automated solution for prior authorization would be a single, standard electronic PA process applicable to all service types that include medical, pharmacy, laboratory, radiology and durable medical equipment (DME) services to reduce the administrative burden placed on payers and physicians alike. Read the AMA's workflow recommendation regarding the automation of prior authorization.
Access the, "Standardization of EFT transaction and process," white paper for more information on AMA's efforts to push for a standard EFT enrollment application and accompanying electronic health care transaction
The "Standardization of the claims process" white paper summarizes the AMA’s recommendations to eliminate significant administrative waste from the health care system by simplifying and standardizing the current health care billing, payment and claims reconciliation process based on areas of process improvement in the claims cycle.
The AMA "Standardizing CPT® codes, guidelines and conventions" white paper asks for a standardized claim processing platform that would include the four basic tenets:
- expansion of Health Insurance Portability and Accountability Act (HIPAA)-designated Current Procedural Terminology (CPT®) code set to include the CPT® codes, guidelines and conventions;
- a HIPAA standard claim edit package that is fully transparent and consistent with the CPT codes, guidelines and conventions;
- a HIPAA standard payment rule set (e.g., multiple procedure reduction logic rule); and
- a HIPAA standard payer identifier.
Cost estimates of inefficient health care claims processing, payment and reconciliation are between $21 and $210 billion. In the physician practice, this expense comprises 10-14% of practice revenue. The administrative simplification objective within the physician practice is to encourage automated, real-time health plan transactions, along with the reduction of manual processes throughout the physician’s claims management revenue cycle, increased health insurer claim payment process transparency and reduced ambiguity. Access the first white paper addressing this matter, "Administrative simplification."