Claims challenges expected to persist


Claims-resolution challenges expected to persistPhoto used with permission from Shuttershock.com

Some insurers were slow to adopt digital payments in 2012 and the ICD-10 precursor conversion ANSI 5010 reduced some claims resolution, the EHR and medical billing company athenahealth found in its annual review of payer data.

“2012 was a harbinger of things to come in the areas of claims resolution, provider collection burden, co-pay information accuracy, electronic enrollment and incentive program transparency,” the company said in its PayerView report.

Payers as a whole — with some exceptions — have been dragging their feet in electronic transactions, with 65 percent still requiring fax or mail enrollments, athenahealth found. In February 2012, after the HIPAA-mandated ANSI 5010 conversion, nearly all payers saw severe drops in first-pass claims resolutions, and a “number of major clearinghouses deviated from standards, resulting in large batches of rejected claims," the report said.

First-pass resolutions steadily increased starting in March, as ANSI issues were resolved. But athenahealth — which is going to offer medical practice clients with any ICD-10 disruptions cash advances for outstanding claims — thinks that there “is a high likelihood that the ICD-10 implementation will cause a similar slowing of claims resolution.”

Ahead of ICD-10, athenahealth said its medical practices also saw an increase in reimbursement collection burdens, and that “a more rapid acceleration is expected as new reform measures take effect.” Deductibles were one large source of provider collection burdens, along with increases in high-deductible plans, the report said.

Related to that, the report found providers increasingly focused on the accuracy of payers’ co-pay and benefits administration. Many national plans and Blue Cross insurers fared well, with high benefit accuracy rates, while seven payers returned the correct co-pay in fewer than 50 percent of cases, the report found.

The report also showed significant challenges for Medicaid, a payer that’s expected to pick up slack under health reform with nearly 78 million enrollees by 2021.

While the trends vary across the states, the average Medicaid program had provider reimbursement waiting times of 47 days in 2012, nearly double the average for Medicare and commercial plans. Likewise, Medicaid had an average payment denial rate of 20 percent in 2012, compared to 4.7 percent for the average national commercial payer and 5.4 percent for Medicare.

Photo used with permission from Shuttershock.com.