HEALTH INSURER RANKINGS REVEAL ALARMING INEFFICIENCIES IN SOME STATE MEDICAID PLANS

New York, Illinois, Louisiana, and Texas Rank Lowest in Dealings with Physician

WATERTOWN, MA and BALTIMORE, MD (May 02, 2007) – Poor payment and administrative practices by some state Medicaid programs could lead to an access-to-care issue for millions of Americans, according to the second annual PayerViewSM Rankings issued today by athenahealth, Inc., and Physicians Practice®, America’s leading practice management journal for physicians. The rankings indicate that major contributors to some state Medicaids’ overall low performance with medical providers may be attributed to the slow or, in some cases, non-existent reimbursement policies by some state programs, often confusing paperwork protocols and billing requirements, and the growing trend of some states outsourcing Medicaid programs to underperforming private managed care organizations.

“We are seeing disturbing administrative process breakdowns with some state Medicaid plans that are resulting in a growing number of physicians no longer accepting new Medicaid patients,” said Jonathan Bush, Chairman and CEO of athenahealth.

According to an August 2006 study by the Center for Studying Health System Change, only about half of physicians are currently accepting all new Medicaid patients.

“These alarming trends point to a potentially dangerous access-to-care issue that is surfacing for the more than 50 million Americans enrolled in state Medicaid plans.”

“There is a vigorous national debate on Medicaid underway around whether to reduce or expand funding. What is missing from this dialogue is the acknowledgment that precious health care dollars are being wasted on arcane and inefficient administrative processes in some state Medicaid programs,” Bush continued. “Before broad policy changes are made, it is imperative that we first address Medicaid’s core process problems with fundamental administration.”

As part of the overall PayerView Rankings, athenahealth and Physicians Practice, ranked 12 state Medicaid plans based on seven performance metrics designed to reflect the experience of the athenahealth national medical provider client base in billing these Medicaid plans for all four quarters in 2006. When compared to all payers nationally, state Medicaids dominated most categories with respect to low performance. Other factors in Medicaid programs’ overall lower performance may be attributed to poor fiscal management, non-standard coding practices, and the use of proprietary claim forms as fraud control measures. State Medicaid programs needed a minimum of 20,000 medical claim charge lines for 2006 to be included on the rankings.

Performance of state Medicaid plans varied but indicated an overall need for reform:

New York-Medicaid was the slowest payer to medical providers averaging over 111 days to process a claim. New York was not only the slowest payer among Medicaid plans but ranked the lowest among all payers nationally.
Louisiana-Medicaid had the highest claim denial rate, rejecting claims or requiring back-end rework by medical practices almost 48 percent of the time.
The rankings indicate that Illinois-Medicaid only pays medical claims on the first attempt approximately 30 percent of the time. The state was also the second slowest payer to medical providers averaging over 103 days to pay a claim.
Texas-Medicaid ranked near the bottom on a number of metrics, specifically, on the clarity of why the program rejects a medical claim. Texas physicians resubmitted denied claims at least twice over 47 percent of the time. Texas also ranked second to last with their compliance with national coding standards.
Some states are trying to deal with the increased complexity and administrative hassle associated with the billing and claims process. The rankings point to the growing trend of states outsourcing the management of state Medicaid programs to private managed care organizations. Many states feel that private carriers may have more modern systems that can help offset rising health care costs. However, some states, like Georgia, are experiencing tremendous frustration in dealing with new managed care programs.

“Efficiency was a primary goal behind the implementation of Medicaid managed care in Georgia, yet after a year the administrative hassles and low payments associated with the program cancel out the intended advantages. The Medical Association of Georgia (MAG) has had to troubleshoot more than 500 complaints from physicians, most of which should have been eliminated by the Care Management Organizations (CMO) shortly after the start-up,” said S. William Clark III, M.D., MAG President. “In addition, we’ve become increasingly concerned over the lack of specialty care available to patients in some parts of the state. If the needs of the patient cannot be addressed, we have an even more serious problem at hand.”

To view the 2007 PayerView Rankings including state Medicaid programs, visit www.athenaPayerView.com.

Source: athenahealth