Docs and Insurers Posture on Report Cards, But Is Silence the Real Goal?

Millenson  Report cards are back in the news.

The Washington Post (via Kaiser Health News) is warning about the difficulty of rating individual physicians. Meanwhile, spokesmen for the insurance industry and the doctor industry (a/k/a the American Medical Association) are content with huffing and puffing about the perfidy of any report card that’s about them.

 In late July, for instance, the AMA sent letters to more than 40 health insurance companies requesting they investigate the reliability of their physician rating programs in the wake of RAND studies casting doubt on how low-cost and high-cost doctors are classified and on some quality rankings. That work was partly funded by the AMA and the Massachusetts Medical Society, which is also suing the Massachusetts Group Insurance Commission (GIC) over its physician ranking effort.

I'd have more sympathy for the docs except for the fact that the GIC effort has actually been one of the most intensive in the country to take into account quality as well as cost. Moreover, GIC executive director Dolores Mitchell has been a fierce pro-consumer advocate, not a role typically filled by your local medical society. (One local profile called her a “change agent” who “doesn’t take any guff.) And despite the complaints, there has been very little effort by the AMA or most other medical societies to work with insurers to provide the kind of timely clinical data (as opposed to claims data) that would make report cards more useful to patients.  The search for the perfect is too often a deliberate tactic to delay the implementation of the good.


But at least when it comes to objecting to cost comparisons of individual physicians, the docs have the facts on their side. The insurers, in contrast, win the chutzpah award for their reaction to the federal government’s website. In response to the government’s plan to show how often insurers deny claims, America’s Health Insurance Plans (AHIP) sent a letter to the government claiming, in effect, that the report card needed to be risk-adjusted for doctor stupidity.

Join me please, in reading between the lines in this story from the Los Angeles Times : 

“’Providing information about claims denials without providing proper context does not begin to tell the whole story,’ said Robert Zirkelbach, a spokesman for the group, who said claims are often denied because a provider sent a duplicate claim or submitted a claim to the wrong health plan.”

The seeming logic of this objection falls apart completely on closer inspection. The reality is that the same doctors are on the panels of virtually all health plans in most markets. If one plan’s denial rates are higher, the reason is either the physicians (and their staff) are dumber when they fill out only that claim form or that claim form is more difficult to fill out or that health plan's policies actually result in denial of more claims – the latter two possibilities meaning the plan has earned its bad grade. The same holds true if a provider that dominates one market gets a much lower grade than a provider that dominates a different market. Again, it’s either the fault of the insurer or – to paraphrase AHIP– it’s because “my doctors are dumber.”

 The unfortunate reality is that today’s report cards still only scratch the surface of what patients want to know and deserve to know, as St. Louis Post-Dispatch reporter Jeremy Kohler makes clear in an Aug. 1 account, trying to track down the details after being tipped off about a wrong-site surgery at a local hospital. His piece is entitled, “Serious Medical Errors, Little Public Information.” Indeed, patients continue to fight just to see their own medical information , much less information on doctors.

When it comes to patient safety and quality, a deadly silence , alas, too often continues.

Spread the love

Categories: Physicians

13 replies »

  1. as a note we deny a lot more claims then we use to. In the past we could pend a claim for accident details, third party liability, or medical notes. Now that is now allowed, we have to deny the claim and request it

  2. excellant point Margalit. Not all denials are bad. If I deny a 100 claims for lack of medical necessaity that is far different then me denying 100 claims for accident details or so I can sudit. The data is already there it just needs used.
    If someone takes my denial data and starts degrading me though for legit denials I’m going to be unlikly to share it. We deny maybe 5% of claims but 4.5% are for good reasons.

  3. The vast majority of claims are not filled by anybody. They are created electronically by a practice management system and sent out, as Nate said, to a clearinghouse which then sends them to the appropriate payer. The clearinghouse will not reject any claim as long as it is properly formatted because they have no eligibility information.
    Payers will reject claims for incorrect information (bad demographics, bad billing information, etc.) – this is the practice’s fault. They fix the claim and send it out again.
    Payers will deny claims for lack of medical necessity, uncovered services, request for additional medical records, etc. A large amount of this can still be the provider’s error. It can be fixed and resubmitted and eventually appealed if necessary. The remainder are the “real” denials.
    The beauty of this system, if there is one, is that each rejection and each denial has a code associated with it which explains if the rejection/denial was because the payer decided to just not pay, or if this is a fixable clerical error.
    Differentiating the unpaid claims by those codes adds a little bit of complexity to the database query and lots of light to the end results.
    It is really rather simple to present meaningful data.

  4. I agree that the public needs information about the cost of health care. So do the doctors ordering this care. For plans to pay different providers vastly different fees and keep these contracts secret from the doctors ordering the services while blaming them for variation in the cost of health care shows just how cynical they can be. Tiering is just another gimmick allowing plans to appear to be doing something, while blaming the doctors and shifting costs to patients.
    At least the AMA and the Massachusetts Medical Society had the decency to have an outside expert perform a study to see if the scheme worked. Where is the managed care study? They just seem to try whatever they (or their biggest customer) want.

  5. Brad, I agree with you completely about the problems with measuring individual physicians dealing with chronic disease and the like. But the kind of work done by the GIC and that has been done with others to try to deal with some rough issues — say, appropriate drug prescribing — has not always been supported by the profession.
    In other words, you are right on the science. And some medical societies (mostly the FP’s and internists) have been very progressive. Most in-the-trenches docs are less progressive than the progressives at the top of the FPs and ASIM, alas. Good for you for trying to do measurement right or not do it at all if it can’t be done right. From where I sit, the payers try to measure whether it works or not and most — most, not all — physicians are outraged at being measured. The AMA expresses that view well.
    Nate: Again, sorry if blog shorthand blots out subtleties. Your point about HMOs vs. PPOs and the like is fine. My point is that if you can’t blame differences in apples/apples comparisons on doctors being unable to fill out claims forms or the like. And to presume that you have more Taft/Hartley people or the like is, to repeat, the same as a doctor or hospital saying, “I get all the tough cases.” Maybe. Or maybe in a plan of, say, 50,000 members, the differences wash out.
    As with payer report cards on doctors, the doctors’ report cards on payers may be inaccurate for various reasons. But it’s not like the insurance companies are going out of their way to “risk adjust.” Instead — and you are not the AHIP spokesperson, you’re being more thoughtful — we get blanket denials of accuracy or usefulness.
    Based on many years in this field, I think that the leadership of the AMA and of AHIP have an equal interest in their members’ flaws being transparent to the public; that is, little to none. Unfortunately, it is only the appearance of flawed report cards that persuade some folks that they need to get involved with improving the data rather than complaining about the report card.
    Some folks. Not anyone on THIS blog. 🙂

  6. you can in theroy reject a claim at the cleearing house EDI level, legally you can no longer reject a claim, anything submitted is supposed to be paid or denied and an explanation sent.
    clearing houses are not very willing to do this though, they want the flow through at .40 per claim rather it is valid or not and if it is the first or fifth time that month it has been submitted.
    ” are the employees of your plan stupider than the employees of the competitor?”
    If I am a taft hartley TPA that writes trade skills then yes without a doubt my members are less educated then a TPA that targets universitys. This is very common for payors and insurers to excel in certain market segments so it is very common to have populations with large varations in demographics.
    All my members are very smart in case any are reading though.
    ” When you blame “benefit design” or the like you also miss the point: the job of the insurer is to be efficient and effective and pay claims on time. If you can’t do that, you’re not doing your job.”
    Your being naive here. You really want to argue a plan design that allows MRIs without any limitations is no different then one that requires every MRI be pre-certifed? If I don’t have the pre-cert or records to process the later I have to deny the claim. How am I failing to do my job by doing my job and requiring a pre-cert before paying the claim? I hope you can see how your argument makes no sense at all. Lacking any understanding of the claims process I see why your making these mistakes in logic but the fact remains you don’t understand the process well enough to be talking about it.
    Compare HMO to PPO plans. Without a referral lab test, specialist vists and all sorts of care would be denied. By your logic all HMO plans are thus bad compared to PPOs because their denial rate is higher. Your argument is flawed from the beginning.

  7. MIchael
    I am sorry, that is a non-answer. As societies and thoracic surgery goes, measurement is much easier and to examine and risk adjust CABG’s where registries exist and things of that sort are closely followed, you are talking about an easier task. Medical and chronic conditions are far more difficult, and while medical societies may be somewhat obstructionist–not all, many docs are not afraid of transparency and measurement (grads after the 90s) and there is only so much one can do in fragmented system. I am no shill for medical societies, but it would serve you will to look at the position statements of some of the more influential medical societies to see what they say and where they stand before you post up. You might be very, very surprised.

  8. To Brad’s question about non-claims data: the database from the Society of Thoracic Surgeons uses clinical data, very well risk-adjusted. It was hand-collected when the system started and may be automated by now. Although physicians complaining about lack of automation while resisting computerization of offices and hospitals for decades is a bit much. There are flaws with claims and other data. There are now efforts to use data mining techniques, etc., to fix them. To my knowledge, no organized professional societies have been leaders in trying to make data better, although they do work well in a defensive mode (sometimes).
    Why is that a surprise? All members of all trade associations, be it truck drivers, real estate agents or doctors, are above average — in the eyes of the trade association.
    Nate: I’ll concede “Most” if not “all” as a rhetorical point about the doctors. But you miss the larger point. Blaming employees is like blaming doctors: are the employees of your plan stupider than the employees of the competitor? When you blame “benefit design” or the like you also miss the point: the job of the insurer is to be efficient and effective and pay claims on time. If you can’t do that, you’re not doing your job. Although, I guess, “our customers are more difficult” is a good reason, just like “my patients are sicker.” Sometimes, that is absolutely true. And sometimes, just like doctors who genuinely believe it about their own practice, it’s nothing but self-deception.

  9. The truth is that you can’t use “claim denial rates” for anything without having a whole lot more information. I look at this data every day.

  10. “The seeming logic of this objection falls apart completely on closer inspection.”
    This just killed any thought you might understand how claims are filed. If you don’t understand the process why not just say so or leave it alone or ask around before you make your self look bad and impeach the entire post?
    “The reality is that the same doctors are on the panels of virtually all health plans in most markets.”
    First error, and a big one, is while a large number, no where close to most, doctors might be on the same panels their concentration of care under those plans can be 30% different or more. For example MMO and Emerald are two networks in Cleveland, MMO is centered around Cleveland Clinic and Emerald around UH. While both hospitals are contracted with both networks the percentage of claims are polar opposite. Emerald has a fraction of the claims from CC that MMO does. If CC was a bad biller MMO would appear worse because they receive so many more claims from CC.
    ” or that claim form is more difficult to fill out”
    I just love how people with no exposure to billing keep this myth alive. Most providers have one clearing house, that clearing house sends one 837 to the payors clearing house, what in the heck are you talking about?
    Now lets examine just a couple of the considerably more valid and real options you either aren’t aware of or chose to leave out ot float your narritive.
    1. Lets say you have the State of X as a client for 10 years. They make a change and go with a new payor. Doctors are notorisouly bad at updating files and will continue to bill the old insurance company for years after the State changed. By your argument as of the date of that change all of a sudden the origina payor is now bad becuase their denials just sky rocketed. Great logic.
    2. Plan designs, if you have a group with a quricky plan design you can end up denying a lot of claims, it is no reflection on the payor ir purly a product of the benefits.
    3. Make up of the group, as terribly inept as physician billing staff is, employees do their darnest to match them. We have certain groups that are just full of knuckle heads, they can’t show the right cards or go to the right providers to save their life. Again no reflection on us.
    4. Above also comes into play in communities where we might insure the school or county, providers seem to always bill them first even when the spouse or kids might have primary coverage with someone else. Again not our fault the claim is billed wrong.
    5. There is a huge size bias. 6 could be geography. If a doctor processes 50 claims a day with one insurer and 1 a week with another they are more likly to get it right with the one they are more familiar with. That doesn’t mean the smaller one is worse or the one from out of town is it just means they don’t work with each other nearly as much.
    Now that your argument as been destroyed we all clearly see the problem with people that don’t understand a system trying to impose reporting requirements and regualtions.

  11. Michael:
    “And despite the complaints, there has been very little effort by the AMA or most other medical societies to work with insurers to provide the kind of timely clinical data (as opposed to claims data) that would make report cards more useful to patients.”
    Outside of claims or administrative data–which is usually available (yes, I know, that is another post), but subject to suboptimal analysis, incompleteness, inability to risk adjust, etc., what other efforts that would not require extensive hand review and submission do you suggest? You are right, the docs can whine quite a bit, but frankly, a lot of it is justified. You lost me–what do you suggest the medical societies and AMA offer up alternatively?
    Also, on the denial front, dont forget certain plans might have a greater number of union employees, large corporate contingencies, or healthy individuals–which may have greater or lesser complaints related to back pain and the like, thus, creating demand for more potentially deniable services.

  12. Well, maybe our way of thinking is to blame. Too many people want to take advantage and make claims if those cards would be publicly “filled in”. taking them into court as a proof.

Leave a Reply

Your email address will not be published.