Two Health Insurance Companies Can Play That Game

Health insurance providers are now rating payers and in the insurance ratings game, Aetna looks to be doing better than other big health insurance plans.

There are several 'payer rating' sources now available, each with their own approach. One of the more intriguing is published by the Verden Group. The VG tracks the policy changes that payers make on a daily basis, alerting providers "to any administrative and clinical policy, procedure and reimbursement changes occurring in the networks in which you participate, at the time these changes are occurring." Think of VG's service as a 'policy aggregator' that 'pushes' notice of policy changes out to specific providers (providers that sign up for their Alert service).

From a broader perspective, this business model is a classic example of niche identification. Providers are forced to proactively monitor the websites of the networks in which they participate for changes in areas such as prior authorization procedures, mailing addresses, credentialing requirements and processes, claims submission and approval, benefit design, and communications standards and protocols. VG removes the burden from providers - albeit for a fee.

A side benefit of all this monitoring and data collection is VG's quarterly Managed Care Company Ratings report. The Report analyzes each major health plan's impact on providers in the areas of cost of compliance, timeliness of notification of policy changes, volume of changes, and ease and clarity of communication. VG then weights these areas and the result is an aggregate rating.

In contrast, athenahealth's payer rating system, PayerView(sm) is designed to evaluate the "ease of doing business with a payer." Compared to Verden, PayerView appears to cover a broader spectrum of the provider-payer relationship, and is more financially oriented, although it does consider administrative performance and medical policy complexity (similar to Verden). athenahealth acts as a billing agent for their provider clients, and thus has extensive, hands-on knowledge of the gritty business of submitting bills and getting paid (or not).

(observation - while athenahealth's information depth is certainly impressive, it is not very accessible - they do a poor job of explaining acronyms and use jargon extensively with little explanation)

I'll let interested readers puzzle thru athenahealth's PayerView on their own. The good news for Aetna is they come out on top - paying claims quicker and more accurately than other health plans. The health plan also reduced its denial rate by 10.6%, and remained the fastest paying health plan. Aetna was closely followed by CIGNA.

Aetna looks pretty good to the folks at Verden too, scoring at the top of the 18 payer list in cost to provider (changes that added admin expense, altered reimbursement, increased admin time and/or complexity) and clarity of communication.

One of their lower-weighted areas is notification period - the time between initial posting of a policy change and that change's effective date. If there's one thing that drives providers nuts it is the denial of a claim or procedure because the provider did not follow a process that no one told them about.

HealthNet ranked worst in this area followed closely by GreatWest. But most health plans were only marginally better.

This reflects poorly on health plans; providers will likely (and justifiably) assume this is due to a lack of concern about these issues on the part of management.

What does this mean for you?

Health plans that understand the importance of the provider - and do more than just talk about it - are going to do better than their rivals that don't value providers.