Plans collaborate with AMA to save $8 billion in claims


More than $8 billion has been saved this year as a result of the American Medical Association's (AMA) Heal the Claims Process campaign

NATIONAL REPORTS-More than $8 billion has been saved this year as a result of the American Medical Assn.'s (AMA) Heal the Claims Process campaign, and billions more could be saved through systematic changes.

With the support of more than 130 organizations-including private health insurers Aetna, Humana, Regence, UnitedHealth Group and Cigna-the campaign seeks to cut unnecessary administrative costs by bringing transparency, simplicity and consistency to the medical billing and payment system.


AMA's annual National Health Insurer Report Card showed that error rates dropped for private health insurers on paid medical claims from 19.3% in 2011 to 9.5% in 2012, amounting to savings of $8 billion.

"The campaign has worked to make the claims process more efficient, more effective and less frustrating for all involved," says Dr. Stack. "Eliminating fraud, abuse and waste is always a mantra for those of us trying to stave non-value within healthcare expenses."

By working with insurers to identify frustrating roadblocks, the campaign has established three ways to improve the current claims process:
● Implementing an automated, electronic prior authorization system would help streamline what can often be a confusing, tangled process. Because of this, Dr. Stack says, the campaign advocates for a robust methodology using specific HIPAA remittance codes for electronic prior authorization.

The campaign has also worked to increase the number of practices that receive payments using electronic funds transfer. According to Dr. Stack, an industrywide switch to an electronic system would have a substantial impact.

"We could save the industry over $11 billion just from that," he says.

● Advancing toward real-time claims adjudication would make the process more efficient.

"At the point of service, physicians should be able to verify a patient's eligibility with the insurer, the fee schedule for the insurer in order to accurately and correctly tell the patient what their liability was, and what the cost of the services will be," says Dr. Stack.

● Finally, individual providers are already required to have a National Provider Identifier (NPI). Requiring all payers to hold a unique health plan identifier (HPID) would also reduce confusion for providers.

"By doing that, we anticipate a marked improvement in the efficiency of the system," Dr. Stack says. "The provider community would know which payer is viable for payment of a claim and with whom to communicate when issues arise. There is a lot of confusion surrounding that in the current process."

While the overall goal of the campaign is to reduce waste, it also aims to eliminate tensions between physicians and payers so that, in the end, the patient can be the primary focus.

"We really want to maximize the amount of time that physicians can spend with the patients rather than pushing papers and doing paperwork," says Dr. Stack. "Inappropriate denials, down-codes, filing appeals and friction between the payer communities; is an enormous dissatisfaction for everyone involved."


According to annual Rankings released by athenahealth, Inc., a provider of practice management services for physicians, payer performance in 2011 remained flat in terms of paying physicians promptly. Findings also showed that payers were challenged by shifts in technology and new compliance obligations that affected payers and their industry partners.

One major shift that occurred was the conversion to 5010, the new electronic data format now required in transactions, code sets and identifiers. Because the conversion started in late 2011, payer performance for 2012 is expected to either remain the same or decline. ICD-10 could also slow the process.

The report also found that major payers and Medicare had increased days in accounts receivable (DAR) rates from 2010. Medicaid was the only payer to show improved DAR rates.

Three insurers participating in AMA's Heal the Claims Process campaign were ranked by athenahealth among the top payers in both the national commerical and major payer categories. Humana took the lead among major payers, with Aetna ranking second. UnitedHealthcare placed third, marking 2011 as its fourth year in the top three.

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