Health Insurer/Payer Relations Tips
AMA practice tip: Interacting with the Disease Management industry
Employers, health insurers and the federal government are looking at Disease Management (DM) as a means of harnessing health care costs through the control and prevention of chronic diseases.The types and intensity of DM services can vary. DM can either offer invaluable tools for patients and physicians or be a major obstacle to receiving and providing quality health care. Private Sector Advocacy has created two resources to assist physicians and their practice staff with interacting in today’s DM industry. “Disease Management and chronic diseases” provides a basic overview of the DM industry, and “Demystifying Disease Management: What physicians need to know for their patients and their practices” focuses on the impact DM may have on the physician practice and offers physicians some strategies for interacting with the DM industry.
AMA practice tip: Creating a patient registry to manage chronically ill patients’ care
Patient registries assist physicians in identifying and managing the health of patients who have chronic diseases. Increasingly, physician practices are using patient registries to facilitate and improve quality of care and as a means to participate in and/or check on the validity of their results for pay-for-performance programs. The AMA Private Sector Advocacy unit created “Optimizing outcomes and pay for performance: Can patient registries help?” to educate physicians on the pros and cons of implementing these registry systems.
AMA practice tip: Filing a complaint
The AMA Practice Management Center has made it easy for you to register complaints about health insurers and other payers. Visit www.ama-assn.org/go/clickandcomplain to access an interactive map that provides each of the avenues through which you can submit a payer complaint in your state—through your state insurance commissioner, your state medical association or the AMA. AMA members may contact the AMA Practice Management Center at (800) 262-3211 for additional assistance.
AMA practice tip: Seven-step process to challenge health insurers’ ratings
The AMA Physician Practice Advocacy unit created the educational resource “How to challenge your ‘profile’ or placement in a tiered or narrow network” for physicians to reference when challenging their network placement with health insurers. This resource offers physicians seven steps that address the problems physicians have identified with these types of programs: the use of claims data, inadequate risk adjustment, lack of an appeal mechanism and invalid ratings.
AMA practice tip: Receive payment for your out-of-network services
Physicians’ ability to provide their communities with quality care is dependent on their ability to keep their practices financially viable. It is therefore important that physician practices pursue appropriate and fair payment that is consistent with legal and community standards for legitimate services provided. The AMA Practice Management Center has developed the educational resource “Holding health insurers accountable for out-of-network services” to help physicians as they seek appropriate payment from health insurers that consider the physician out of network. This resource provides details about what out-of-network physicians might expect when dealing with the health insurer, how these physicians can stay informed about payment laws and issues, and how they can collect fair and accurate payment for their services.
AMA practice tip: Getting paid what you deserve for out-of-network treatment
The AMA has developed the educational resource “Out-of-network payment challenges for the physician practice” to provide physicians and their practice staff resources to understand a third-party payer’s obligation for payment to out-of-network providers. The resource explains some of the payment challenges that arise when a physician who is considered out of network requests payment from a patient and/or health insurer.AMA practice tip: New Health Insurer Code of Conduct and physician resource from the AMA
The AMA has developed a Health Insurer Code of Conduct that sets forth clear principles for health insurers to follow when setting and administering medical care and payment policies. To help physicians and their advocates hold health insurers accountable to the fair business practices that the code of conduct addresses, the AMA offers a unique resource to assist you monitor health insurer compliance.
Comprehensive and empowering, the physician resource “AMA Health Insurer Code of Conduct Principles: Explanations and Strategies for Enforcement” includes:
- Excerpts from the National Managed Care Contract, which is based on the most physician-favorable managed care laws from around the country
- Managed care legislative strategies and model bills
- Settlement provisions that certain health insurers have agreed to abide by
- Information on health insurer fines and CEO compensation
- Physician practice resources that empower physicians in managed care interactions, such as claims processing, managed care contracting, and contesting physician profiling and tiering results.
AMA practice tip: 2012 AMA National Health Insurer Report Card finds dramatic improvement in first-pass payment accuracy
The AMA’s National Health Insurer Report Card provides an annual check-up for the nation’s largest health insurers and diagnoses the strengths and weaknesses of the systems they use to manage, process and pay medical claims. A cornerstone of the AMA’s “Heal the Claims Process”™ campaign, the report card both highlights improvements in the industry and addresses areas of concern that demand attention.
AMA efforts with health insurers cut the number of medical claims paid incorrectly by large health insurance companies in half, according to the 2012 findings released at the AMA’s annual meeting on June 18th. Error rates for private health insurers on paid medical claims dropped from 19.3 percent in 2011 to 9.5 percent in 2012. This improvement resulted in $8 billion in health system savings due to a reduction in unnecessary administrative work to reconcile errors. While dramatic improvements were made this year, the AMA estimates an additional $7 billion could be saved if insurers consistently pay claims correctly.
“Paying medical claims accurately the first time is good business practice for insurance companies that saves precious health care dollars and frees physicians from needless administrative tasks that take time away from patient care,” said AMA Board Chair Robert M. Wah, M.D. Access the report card’s 2012 findings, including denial and accuracy rates and claims processing timeliness. You can also watch an archived webinar that details the findings and learn more about the “Heal the Claims Process”™ campaign.
AMA practice tip: Eliminating unfair discounts
Physicians are regularly solicited to participate in preferred provider networks (PPNs) via participating provider agreements. But how does a physician know if the agreement is beneficial for the practice? In today’s market of rental networks, it is imperative to understand which organizations physicians are contracting with and what the agreements should contain. View the webinar, “Eliminating unfair discounts” to learn how preferred provider networks work, what the difference is between a primary and secondary provider network and what should be contained in an agreement. This webinar also provides an update on the AMA’s related legislative activities.
AMA practice tip: AMA resources help physicians take charge of their data
Public and private health insurers are increasingly using physician data to drive their decision-making processes on new payment methodologies, network design, patient education, and health services availability and delivery. In addition, they are using performance data to rate the quality and efficiency of physicians. Three resources from the AMA are designed to help physicians access these data and strategically use them to improve practice efficiency and delivery of care, as well as ensure that payers and other reporting bodies are not misusing the information.
Take Charge of Your Data is a guidebook designed to help physicians understand and verify the accuracy of complex physician data reports used to profile physicians. The guidebook was created to be used in tandem with the with the AMA’s Standardized Physician Data Report, which provides a uniform format for displaying physician data. Used together, these resources provide physicians with a roadmap to understanding how to use the payer-provided data to verify the accuracy of their profiles and assist them in providing exemplary care to their patients. Additionally, through the creation of the Guidelines for Reporting Physician Data, the AMA is working to improve the quality and utility of physician data reports.
Visit www.ama-assn.org/go/physiciandata to access these resources and find additional information on how to use these exciting tools.
AMA practice tip: Webinars about payment bundling, pay-for-performance and more
In two webinars, you can learn more about key concepts from two authors of the AMA’s “Evaluating and negotiating emerging payment options” how-to manual. The authors discuss how this manual helps physicians who are considering transitioning from fee-for-service payment to budget-based reimbursement. Unlike fee-for-service payment which rewards volume, the primary driver of the economic result in budget-based payment systems is the extent to which the actual cost of providing care to a patient population varies from the projected budget for those costs – physicians who come in at or under-budget prosper, while physicians who exceed the budget are penalized.
These webinars are archived online, so you can watch them at your convenience. For an overview of the manual and how it can help you evaluate, negotiate, and manage budget-based payment systems, including payment bundling, pay-for-performance, withholds and risk pools, capitation and shared savings, view this 12-minute introductory webinar. You can also view the in-depth version of this webinar, which goes into more detail on each of the manual's chapters, in addition to providing an overview of the manual and its concepts.
AMA practice tip: Access key payer information quickly and easily
Navigating the websites of health insurers to find a piece of information can be complex and tiresome. To ease this process, the AMA compiled a list of direct links to the most frequently-sought information for many major payers. Visit www.ama-assn.org/go/payerpolicies to access this resource and reduce the time you an your staff spend searching for answers.
AMA practice tip: Stopping unfair payer practices
Do you want to do something about an unfair health insurer business practice but haven’t seen results after taking it up with the health insurer? Filing a complaint through the health insurer’s internal complaint submission process isn’t your only choice. Visit the AMA Practice Management Center to access the Complaints and Disputes section of the site to learn about the various complaint mechanisms available to you, including your state’s Department of Insurance and the health insurer settlement compliance dispute process. File a complaint. Hold health insurers accountable to fair business practices.
AMA practice tip: Patient education on differences between Medicare and Medicare Advantage
The AMA has created two new educational resources for current and potential Medicare Advantage beneficiaries. AMA members can use these patient educational resources to help educate their patients and staff on the benefits and problems associated with participation in Medicare Advantage plans. The first resource, “What you need to know about Medicare Advantage,” provides basic information on the program, including what to expect in terms of benefits, enrollment and health insurer marketing of these plans. The second resource, “Which plan is right for you,” provides a brief overview of the different types of Medicare Advantage plans, including HMOs, PPOs and private-fee-for-service plans.
AMA practice tip: Medicare Advantage private fee-for-service (PFFS) plans
PFFS plans are perhaps the most confusing and least understood of the various kinds of Medicare Advantage plans that are in operation. They also are the fastest growing type of Medicare Advantage plan. The AMA has created a new one-page flyer “10 things you need to know about Medicare Advantage private fee-for-service plans” as a quick reference to aid physicians and their staff about the basic operation of these plans.
AMA practice tip: Learn how to achieve and maintain a stellar reputation among patients and potential patients
Do you wonder what your patients say and think about your practice, and what you can do to improve and maintain its reputation? Your practice is a business, and like any business, its success depends on creating and maintaining customer (i.e. patient) satisfaction and loyalty. You must be aware of, and responsive to, patient needs and preferences. The AMA resource, "Managing your reputation," offers you steps to help ensure you and your practice achieves and maintains an excellent reputation among patients, their friends and family, and other potential patients.
AMA practice tip: AMA resources help physicians take charge of their data
Public and private health insurers are increasingly using physician data to drive their decision-making processes on new payment methodologies, network design, patient education, and health services availability and delivery. In addition, they are using performance data to rate the quality and efficiency of physicians. Three resources from the AMA are designed to help physicians access these data and strategically use them to improve practice efficiency and delivery of care, as well as ensure that payers and other reporting bodies are not misusing the information.
Take Charge of Your Data is a guidebook designed to help physicians understand and verify the accuracy of complex physician data reports used to profile physicians. The guidebook was created to be used in tandem with the with the AMA’s Standardized Physician Data Report, which provides a uniform format for displaying physician data. Used together, these resources provide physicians with a roadmap to understanding how to use the payer-provided data to verify the accuracy of their profiles and assist them in providing exemplary care to their patients. Additionally, through the creation of the Guidelines for Reporting Physician Data, the AMA is working to improve the quality and utility of physician data reports.
Visit www.ama-assn.org/go/physiciandata to access these resources and find additional information on how to use these exciting tools.
AMA practice tip: What is the process of economic profiling?
An increasing number of health insurers use cost-of-care data from claim databases to profile physicians for network selection. Health insurers post report cards, containing these profile results, on their Web sites in an effort to provide incentive for patients to seek care from the lowest-cost physicians. As an expert consultant to the AMA, J. William Thomas, PhD, has written “Economic profiling of physicians: What is it? How is it done? What are the issues?” Available to AMA members at www.ama-assn.org/go/pfp, this ten-page paper details the process health insurers use to profile physicians based on cost.
AMA practice tip: Questions to consider before participating in a pay-for-performance program
The AMA’s Private Sector Advocacy created the “A physician’s guide to evaluating incentive plans” resource to encourage physicians to evaluate incentive plans for their potential to improve health care quality and their ability to operate in an ethical and fair manner. This resource provides questions and observations that can be useful when looking at common properties of pay for performance and other physician incentive programs.
AMA practice tip: Evaluating pay-for-performance programs
As pay-for-performance programs become increasingly common, the AMA has created principles and guidelines to outline how the physician community can work to ensure that pay-for-performance programs are positively structured and appropriately applied. The AMA believes pay-for-performance programs must align with the following five principles: (1) ensure quality of care, (2) foster the relationship between patient and physician, (3) offer voluntary physician participation, (4) use accurate data and fair reporting and (5) provide fair and equitable program incentives. Visit www.ama-assn.org/go/pfp to access these AMA principles and guidelines.
AMA practice tip: How to prepare for physician profiling
The AMA’s Private Sector Advocacy created the educational resource “Physician profiling: How to prepare your practice” for physicians to reference when preparing for health insurers’ profiling programs. This resource offers physician practices information on the five steps that encompass the basic elements of the physician profiling process: contract language, program metrics, data, coding and patient education.
AMA practice tip: Seven-step process to challenge health insurers’ ratings
The AMA’s Physician Practice Advocacy created the educational resource “How to challenge your ‘profile’ or placement in a tiered or narrow network” for physicians to reference when challenging their network placement with health insurers. This resource offers physicians seven steps that address the problems physicians have identified with these types of programs: the use of claims data, inadequate risk adjustment, lack of an appeal mechanism and invalid ratings.
AMA practice tip: Educating patients about unfair/inaccurate physician profiling practices
While pay for performance (PFP) and other programs that use physician profiling can be a plus when they promote effective, safe health care and adhere to the AMA Principles and Guidelines for Pay for Performance Programs, patients should be aware that many profiling programs are poorly constructed and often focus primarily on finding ways to save money—not on improving care. The AMA, co-branding with a number of state medical associations and national specialty societies, created a poster that physicians can post in their offices to raise patient awareness of the many problems inherent in physician profiling programs. Visit the AMA’s Private Sector Advocacy Web site at www.ama-assn.org/go/pfp to view related educational resources.
AMA practice tip: AMA helps physicians evaluate specific health insurers’ physician profiling programs
To help physicians effectively identify and evaluate both problems and positive practices of specific health insurers’ physician profiling programs, the AMA has constructed a series of charts that analyze how components of these programs compare with the AMA’s five Principles for Pay for Performance Programs. Based on extensive research of public information and discussions with practicing physicians, these charts analyze the Centers for Medicare & Medicaid Services’ “Physician Quality Reporting Initiative” and the profiling programs of four private health insurers: UnitedHealthcare, CIGNA, Aetna and Wellmark Blue Cross Blue Shield.
Each of these private health insurers has reviewed the chart on its program. Physicians can benefit from these analyses in their managed care contracting activities and through AMA and Federation application of these analyses in advocating for change in the design of programs that utilize physician profiling. The AMA anticipates preparing additional charts of major physician profiling programs in the future. Visit www.ama-assn.org/go/pfp under “AMA analyses of health insurers’ physician profiling programs” to view these charts.
AMA practice tip: Analyze key elements of physician profiling programs
The AMA has created a comparison chart of up-to-date information on the physician profiling programs sponsored by Aetna, CIGNA and UnitedHealthcare. This chart is a straightforward tool to help you analyze these programs on key elements common to programs that measure physician performance based on quality and cost-of-care standards. Visit the AMA’s Web site at www.ama-assn.org/go/pfp and select “physician profiling” to view this chart.
AMA practice tip: New AMA resources help physicians understand risk assessment and adjustment models
Two new educational resources from the AMA are designed to help physicians understand health insurers’ use of risk assessment and risk adjustment models and how they might affect the physician practice. “An introduction to risk assessment and risk adjustment models” defines the terms “risk assessment” and “risk adjustment” and provides overviews of the prominent risk assessment and risk adjustment models and their various uses, including profiling physicians and other health care professionals. Because numerous risk adjustment models have failed to predict valid practice efficiency rankings and/or health care expenditures, this resource concludes that risk adjustment systems that fail to accurately account for differences in the patient’s health status and the related costs of care should not be used to profile individual physicians.
Currently, we are unaware of any systems that take into account all of the risk factors that should be considered when using risk adjustment to determine costs of care. A second resource, “Terminology used in physician profiling” helps physicians assess information they receive about physician profiling programs by defining common profiling terms used in health insurers’ physician profiling programs. Visit www.ama-assn.org/go/pfp to access these resources and many others on physician profiling.
AMA practice tip: Workers' compensation eBilling vendor listing
Electronic billing (eBilling) is an effective way to avoid administrative hassles associated with workers’ compensation claims. By switching from a manual claims process to eBilling for these claims, you can decrease administrative costs, receive timely acknowledgement of your claims’ status, reduce the time it takes to submit bills, and get paid faster! Access the AMA's "Workers' compensation eBilling vendor" listing to learn about some of the many practice management system and clearinghouse vendors offering workers' compensation eBilling solutions. This resource will help physician practices adopt workers’ compensation eBilling, by introducing vendors that may assist physician practices in automating workers’ compensation claims. Visit the AMA's workers' compensation toolkit at www.ama-assn.org/go/workerscomp for additional resources, including an interactive map which provides state-specific resources on workers’ compensation medical reporting and billing requirements, state rules and regulations, how to file an appeal, and more.
AMA practice tip: Workers' compensation, property and casualty eBilling toolkit and state-specific resource map
Learn how to automate workers' compensation claims submission and attachment processes in the AMA's workers' compensation, property and casualty eBilling toolkit. Here you can also retrieve state-specific resources, by accessing an interactive may providing information on state-specific resources on workers' compensation and medical reporting and billing requirements, state rules and regulations, how to file an appeal, and more.
Visit www.ama-assn.org/go/workerscomp to access these resources.
AMA practice tip: Webinar offers a clear, concise guide to easing the workers’ compensation billing process through eBilling
Significant changes are occurring in a number of jurisdictions, and many providers and payers are now exchanging workers’ compensation billing and supporting documentation electronically. An unprecedented collaborative effort between payer, provider, industry trade and standards groups, and regulators is advocating eBill initiatives based on national standards, which will greatly help providers take advantage of this much-needed segment of administrative simplification. The AMA has developed the educational webinar “Workers’ compensation eBilling - A rapidly evolving solution to a historic revenue cycle headache!” Industry experts guide you through key topics including the evolution of workers’ compensation eBilling; how stakeholders are leveraging existing practice management systems, clearinghouses and other vendor relationships to automate their workers compensation eBilling and revenue cycle processes; and how you can facilitate this much needed change.
To view this or any other AMA webinar on practice management topics, visit www.ama-assn.org/go/psa-webinars to access the webinar archive.
