This column was originally published in AMA eVoice on June 26, 2008. Dr. Nielsen is president of the American Medical Association.
Has a health insurer or other third-party payer ever inappropriately delayed, denied or reduced your rightful claims payments? If you're like most physicians, I'm sure you answered "yes" to that question.
Have you ever done anything about it? Again, if you're like many physicians, odds are you haven't.
Whether it's because their busy practice schedules simply don't allow them the time to follow up on claims or the frustrations of dealing with health insurers hold them back, a majority of physicians never appeal wrongfully delayed, denied or reduced payments due them. And it's costing them a lot of money.
That's why earlier this month, during the Annual Meeting of the AMA House of Delegates, the AMA launched a campaign to help "heal" the ailing, inefficient system of processing medical claims with health insurers and ensure accurate payment to physician practices the first time they submit a claim. And it strives to empower physicians to demand fair payment from health insurers.
The campaign encourages all physicians and their practice staffs to submit claims accurately and in a timely fashion. And it calls on all payers to fully comply with the Health Insurance Portability and Accountability Act (HIPAA) electronic claims transactions standards and to pay accurately and in a timely manner the first time they receive a particular claim. That includes full transparency with respect to fee schedules, medical payment policies and other information that maximizes efficiency. And it applies to all entities that handle claims, including managed care organizations.
Physician practices spend as much as 14 percent of their total collections to ensure accurate payment for their services, according to the National Healthcare Exchange Services (NHES), a company that specializes in physician underpayment recovery. The goal of the campaign is to help reduce that figure to 1 percent of practice costs.
As part of the campaign, the AMA developed the National Health Insurer Report Card to act as a source of accountability for critical measures concerning the timeliness, transparency and accuracy of health insurers' claims processing.
The report card consists of data from health insurers' Web sites and is supplemented by a single database maintained by NHES, which includes more than 5 million services billed on more than 3 million claims by the respective payers between the second half of 2007 and the first quarter of this year. The database includes claims from more than 7,500 practicing physicians representing 18 specialties from 195 practices in 20 states.
The goal of the report card is to improve the overall efficiency of billing and collections, thereby reducing the cost to physicians, payers, patients and other health care consumers. It includes figures on Medicare and seven national commercial health insurers: Aetna, Anthem Blue Cross Blue Shield, Cigna Inc., Coventry Healthcare, Health Net Inc., Humana Inc. and UnitedHealthcare.
The AMA Practice Management Center offers a number of resources to help you with your practice's internal claims process and appeal inappropriately delayed, denied or reduced claims.
I strongly encourage you to review your practice's internal claims process to ensure that your claims are submitted accurately and in a timely manner to the appropriate payer. Also, don't assume the claims payments you receive are correct. Review all your payments for accuracy, and—perhaps most importantly—appeal the inappropriately underpaid or denied claims.
And please consider automating your practice and filing claims electronically. Research shows that if both physicians and payers use electronic transactions for the estimated three billion claims submitted every year, the health care industry could save more than $90 billion annually.
By taking these steps, I believe we can help improve the claims process for physicians nationwide.
Please send comments, questions, and replies to amaprez@ama-assn.org.
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