WhiteCoat

Rating the Insurers

Sick of getting rated by the insurers?

Physicians Practice magazine had an article in June that rated the insurers. The link to the article online is here. A print version of the article is here -> Examining Payer Performance.

To summarize,
UnitedHealth Group was the worst of the national insurers, rating lowest in patient opinion polls at 65 out of 100 and also ranking worst in hospital reputation with only 8% positive/91% negative scores.
Aetna had a 66 out of 100 point score for patient opinion and had the highest reputation with hospitals at 57% positive/37% negative scores.
A score of 57% is considered the “best”?

In terms of regional payers, Medicaid was consistently rated as one of the worst.

The Medicaid system in New York was by far the worst of the worst, taking more than three times as long to pay as the best Medicaid system and approving only 57% of the charges on the “first pass” compared to 92% of the charges on “first pass” paid by the best Medicaid system. New York Medicaid also had the highest denial rate, the lowest denial “transparency” and the highest noncompliance with national coding standards (more than 100 times greater than the best ranking state).

So is it just a coincidence that a hospital New York was in the news for some bad patient outcome not too long ago?

UPDATE AUGUST 14, 2008
Just found this 2008 AMA National Insurer Report Card.

CIGNA and Humana are at the bottom of the list in timeliness.
CIGNA and Health Net are at the bottom of the list in Accuracy.
CIGNA and United Health reduce the most number of claims to $0 by edits.

Notice a pattern?

15 Responses to “Rating the Insurers”

  1. SeaSpray says:

    Interesting post and article! I think it’s a great idea that payers can be researched publicly and therefore may be forced into being more competitive. The better ones will get more contracts with physicians. The less desired plans will hurt financially and less income will surely get the stockholders attention.

    I don’t understand why it is alright for some payers to be non-compliant with national coding standards, etc.? Really, how are billers able to stay current with the latest changes if there isn’t uniformity?

    And that was an important question asking if the billers are following up on denied claims. As a patient and because I have been home and have time to really pay attention to insurance payments, etc., I have observed that everyone makes mistakes when it comes to collecting money when it comes to payers and providers. By providers I mean the billers for the physicians & the hospital. I do feel sorry for people, especially elderly people that just assume what they are getting billed for is correct. I think there are many people paying out more than they should because insurance companies DO make mistakes (are they really mistakes?) and so do the providers.

    I recently learned from a friend that in the billing group she works for she recently observed that a co-worker never adds the 2nd insurance company to be billed. YIKES!

    Do doctors really know what the people they pay and trust to bill accurately are doing? The article questioned if office staff follows up on denied claims. If I have learned anything from the patient end of things, it is that it is most important to follow up on payer payments because I have brought things to their attention and gotten a better payment for the providers and myself. You HAVE to be persistent.

    Sorry I digressed. It is all so complicated. A patient with medical bills coming in from all over can find it to be a daunting process to follow up on everyone too.

    It just shouldn’t be so hard. Everyone should be able to count on universal rules, period. Oh wait… silly me… I forgot about 5 star rules. ;)

  2. mottsapplesauce says:

    Totally agree SeaSpray. Billing & processing claims is not an easy task. One young woman I spoke with, who works for the Public Welfare Dept in Pennsylvania, said you practically have to be a rocket scientist just to figure out the prior authorization process. Claims are another story.
    With regards to United Healthgroup, I saw firsthand how awful their reimbursements were, & how long it took for our physicians to get paid–or any other provider to be paid.
    A couple years back, a very large commercial insurance carrier, which I’m sorry will remain nameless, was cutting so much from their reimbursements, that the policyholders & their employers were dropping contracts like hot potatoes & seeking other carriers. Needless to say, to win some clients back, this carrier had no choice but to raise it’s fee schedules just to remain competetive.
    I submit high-dollar claims & you wouldn’t believe the excuses I’ve heard for lack of claim payment. Very little are legit, the majority are stall tactics. Diligent follow up is the only way I can get them paid.

  3. TK says:

    Wait a sec, will these “Press Ganey” type scores for insurance companies change their reimbursement like it does ours?@!?!??!?

  4. Marie says:

    What I will give NY Medicaid credit for is that I don’t have to get pregnant to get some medical help. My state apprently doesn’t give a shit if you’re single.

  5. crankylitprof says:

    You mean I can Press-Ganey bomb Keystone healthbastards?

    SWEET!

  6. Marilyn says:

    Helpful information, and very timely for me. Thanks very much.

    Wish I could change my insurer which shall herein remain unnamed; it’s provided (well, we pay half the premium) through my husband’s employer and we don’t have other options. After struggling for 3 months to get my CT scan paid for I was wondering if I’m the only one who has trouble with this insurer. The chart linked to this article shows me that my insurer ranks between 16th and 18th of 21 West coast companies on most criteria. I was going to ask my hospital billing office what they think of my insurer, don’t need to now! My husband will be going to his employment office and talking this over with the human resources manager.

    Why won’t they pay for the scan? Billing error… they say the scan was ordered as if I had been seen on a standard “office visit”, not an “urgent care” visit (though I did go to the urgent care clinic…perhaps this is related to my insurers extremely poor performance in compliance with national coding standards?). The hospital did not obtain their pre-authorization in 24 hours, as required by insurance. Gee whiz. If I hadn’t been so sick and in so much pain (diverticulitis attack with 101.5 degree temperature) *I* would have called the stupid insurance company. Now I’m in the middle of a fight with the hospital and the insurance company. Hospital wants their money from me and I also have to deal with the associated independent contractors (radiologist, pathologist, etc.) that were denied payment for the same reason. I’m sure glad I didn’t perforate…this could have gotten very ugly!

    I am going through the same thing with my colonoscopy. The doc’s office got their pre-authorization and, theoretically, the expected insurance portion. Now I have my EOB from insurer, they have denied half the charge for the procedure. I expect I will probably have to fight to get my mammogram (coming up next week) paid for as well.

    I don’t even want to think about how difficult these issues become for someone with more complicated medical issues (or even someone without bookkeeping/billing experience as I have). This is sure a headache.

    I’m not in favor of a single-payer (read: government) plan, but I can understand why people think it will make things less complicated.

  7. SeaSpray says:

    Marilyn – Who is actually supposed to preauthorize the test? If it was you and you can have your Dr write a statement that you were to ill that might help.

    If it was the hospital… then they have to eat the costs because they dropped the ball.

    But the urgent care clinic made the mistake and so I would think it is up to them if there was an error in how it was ordered. That wasn’t your fault.

    Our pastor’s wife came into the ED with a hand injury and didn’t think to call for her per-cert and the insurance company was denying payment. But she wrote them a nice letter explaining what happened and they ended up covering it.

    Sometimes it just depends who you get and if they will be sympathetic and they will just change things in the system but then not all companies operate the same way. And is it am HMO vs a PPO?

    When I was an inpatient for a week, some one on staff didn’t precert the extra day that I stayed and it was necessary for me to have the extra time. It was the hospital’s responsibility, didn’t do it and so had to eat the charges. I was however responsible for my deductible part of the bill.

    I worked in a hospital. ED doesn’t have to get authorization as it is up to the patients but Admitting does. if they fail to do it then the hospital CAN’T bill you.

    The hospital did try to bill me but I pointed out what happened and then they said I was right but pay the co-pay.

    And I never called ahead about going in to ED for rabies series and the insurance company wasn’t going to pay but then I explained that in our area that was my only place to go and they would rather pay for that then days of me dying up in ICU. It was an emergency and they would have pre-authorized it. She agreed and waived it.

    So don’t give up! :)

  8. Marilyn says:

    Seaspray,

    Thanks for sharing your stories!

    I am with a PPO. I’m not certain whether it was the hospital’s responsibility or the urgent care physician; since the testing was done on an outpatient basis I’m thinking it goes back to the original doctor’s order. My insurance says pre-auth is not my responsibility. The hospital and the clinic are all part of a regional healthcare system so they are all billed through the same system. My insurance said the hospital has to eat the charge, but the hospital is going to make it a miserable on me as they can before they drop it (I am waiting patiently to see if the re-billing goes through). Even the folks in the billing department have acknowledged that their billing system is difficult and confusing. I know person who had to get a lawyer to get this health system off their backs. A friend of mine has been having payments sent directly from his bank to the hospital on a monthly basis; after a year of sending money, suddenly he finds out they are referring to a collection agency, claiming he has made no payments.

    I have to admit I’ve been lazy on this one and relied on phone calls only. In the past I have had good success when writing letters. When my third child was born, I was charged an outrageous amount of money for labor and delivery. The charges were equal to my two earlier deliveries which were C-Sections. I wrote a letter to the insurance asking why an uncomplicated (and un-drugged) natural birth with only a 24-hour hospital stay was costing the same as a C-Section (with anesthesiologist and 5-day stay), politely told them how much money I had saved them and got $3,000 lopped off the bill.

    So, I’ll be patient and wait. And write, if I have to. I’m sure it will work out fine in the end, but it is certainly frustrating to have these things drag on for many months. :-)

  9. SeaSpray says:

    Marilyn- Hold firm, document your conversations and get things in writing from ins if you can. I was fortunate that just phone calls sufficed.

    The insurance I had at the time of my 2nd child’s birth wasn’t paying as much as I calculated they should. I called a couple of times and got nowhere. And then finally someone really listened and told me that they charged to much for anesthesia on a vaginal birth. WHOA! I had a c-section. Problem corrected!

    That pregnancy was also considered high risk and so I had to have 5 fetal non stress tests or something like that… i don’t remember now (he’ll be 20 soon) but they listen to the baby’s heartbeat.

    The ins company was only going to pay for 2 of those tests and yet my OP part of the ins manual indicated they would pay 89% of ALL out patient testing. No where were there any limitations. Several calls and no one cared. My only recourse was to right to headquarters in Washington DC, but as fate would have it…the mother of a patient that came into the ED one night helped me.

    When I heard she worked for blue cross I told her what happened. She said it didn’t sound right and asked for my name and number and said she would look into it.

    Two weeks later, she called and informed me that I was right and that all five tests would be covered. And it took her, an ins person 2 weeks to settle!

    It imperative that people DON’T give up, be diligent… be tenacious until someone really listens. And as far as doctors go…they really need to know if their staff is persistent in going after the reimbursements and if THEY are billing correctly.

    It is complicated for everyone all the way around.

  10. Beth says:

    Perhaps it’s naive of me to believe so, but when I, as a patient, have nothing to do with the billing or payment (other than my co-pay), shouldn’t those two entities deal with between themselves?

    I had two ER visits due to fainting. One I passed out alone at the mall, and they took me by ambulance the two miles to the hospital ($3000 pre-insurance…two miles and they gave me no meds because they couldn’t get the IV started). Insurance is telling me I owe nothing; ambulance company says I owe $250. The other visit was denied for payment twice, because they never heard from me what the circumstances of my car accident were, and if there was car insurance paying for it. I passed out in my parents’ living room and thought I might’ve broken my wrist (and had a decent goose egg on my forehead). They ended up resubmitting it and getting full payment from insurance, but…how do you code so badly that “syncope in living room” gets submitted as “car accident”?

    I’m certain that the insurance companies are relying on people not following up, not questioning, and either just paying to save their credit, or ignoring it and going to collections. Wouldn’t the payment rate from the general public be much higher if they just did it right to begin with?

  11. mottsapplesauce says:

    Absolutely Beth. This is what I strive to do every day. Doing it right is aka sumbitting a ‘clean’ claim. But in this electronic age, may unforseen things happen. Sometimes glitches are on the providers’ end, sometimes the insurers’ end. Most hardcopy claims are scanned & ‘read’ by machine. Sometimes that machine doesn’t read the claim properly. Sometimes the claims have errors, like an invalid ICD-9, or the claim is clean but denies for unknown reasons. For the electronic claims, they are processed in ‘batches’. Once a batch is submitted, a rejection report is printed to identify any claims that rejected due to errors, & it pinpoints those errors to the billing entity so the claim can be resubmitted right away. I think part of the problem is quantity over quality. We rely so heavily on machines to always have the correct data & changes in the patient demographics are often overlooked. One issue I run into quite often, is many of our repeat patients don’t bother to inform us of any changes in their insurance (or address, etc) so we have to make a point to ask them each time they place an order, regardless of how annoying it may be.

  12. SeaSpray says:

    MottsA-that’s interesting. It never occurred to me that it was electronic error other than someone inputting incorrect data. U thought it was all human error.

    At the hospital we always verify. The regular/frequent flier patients sometimes get annoyed because they expect that we should have their info in the system already… and we usually do. But… some people change phone numbers frequently as well as addresses, employers, etc..

    Shoot…sometimes they stand right in front of you and give you the wrong info.

    What they don’t seem to realize is that we don’t want to stop and ask them either. More work for us, but verify, verify. It’s better to take the time up front than to perpetuate errors and delay payment or not ever get paid because it falls through the cracks.

  13. SeaSpray says:

    Correction: I meant to say “I” thought it was all human error.

  14. mottsapplesauce says:

    Well SeaSpray it pretty much boils down to human error. I mean it’s us homosapiens that program the darned things, right?

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