Part of my job is to help clients resolve claims problems with their insurers. I have no actual “power” to get claims paid, but having been at this for almost 25 years, I’m pretty familiar with how “the game” is played, and (most of the time) know whom to call to get a problem resolved.

Which is all well and good for my clients, but what about their providers? Obviously, it’s not my place to resolve their problems (except indirectly), but it might be helpful to my clients (and potential clients) if I knew which carriers were better about paying their claims.

But how the heck would I know that, except anecdotally?

Well, now there’s an answer: athenahealth (they apparently prefer the lowercased version) is a successful claims-processing company based in Massachusetts. Recently, they studied the claims performance data for some 7,000 providers (large and small physician practices), to determine how carriers fared in timely and accurate claims payment.

The study tested for three broad “metrics:” Financial Performance, Administrative Performance, and Medical Policy Compliance. There were, of course, subsets in each of these categories, which combined to present a picture of how well carriers do in paying claims.

One caveat: athenahealth acknowledged that such a small sample (7,000 providers, and 5 million line items) “is not a statistically valid sample.” Still, it gives an insight into the dark underbelly of the process.

I’ll focus here on two general outcomes: overall ranking, and average number of days to pay a claim. In the former category, Humana won the Blue Ribbon, followed closely by (surprise!) Medicare. Perhaps unsurprisingly, WellPoint (aka Blue Cross) came in last. According to a WP spokescritter, the report “has absolutely no statistical significance.” Since the authors of the study had already acknowledged this, I can think of only one reason for such a statement.

In fairness, the study examined such a small percentage of WP’s claims that it’s probably not an unfair conclusion, but surely there’s a way to learn from the results.

Another significant measure is the number of days taken from the date of service to the date of payment. Humana won in this category, as well, while Champus/Tricare (the insurer for military families) came in dead last. I’m sort of sorry to see this: if a commercial carrier had done so, there might be market (or other) pressures to improve; it’s hard to see what kind of pressure could be brought to bear on the government’s own agency.

A couple parting thoughts.

The survey ranked WP first in one category: clear explanations of claim denials. Sometimes, it’s difficult to get an accurate assessment of why a given claim has been denied, so this is positive

I was surprised at how many providers “outsource” their billing. I suppose I shouldn’t be: that’s got to be a tremendous cost-center, and more effectively contracted out.

The results of the survey are available online, and are updated quarterly. It’s actually pretty cool, with interactive tools to see who ranks where, and how.

Be well.

Henry Stern, LUTCF is an independent insurance agent in Dayton, OH. A licensed Continuing Education instructor for Ohio and Kentucky, he has well over 20 years of experience in “the biz.”  He blogs every day (or so it seems) at InsureBlog.