The Massachusetts Hospital Association has released a first-of-its-kind scorecard on health plans' administrative practices serving hospitals in the state. Among the headaches reported, coding remains near the top, hospital executives said.
The report, based on a survey of 31 MHA-member hospital executives, rates the performance of 12 health plans on claims payment, member education, authorization processes and utilization management. Hospitals participating in the survey include 17 acute care facilities with inpatient psychiatric units, 10 acute care hospitals with no inpatient psychiatric services, two non-acute care hospitals and two private psychiatric hospitals.
Coding is an area "where there is significant room for improvement among all plans," respondents to the survey said. The survey also verified that prior authorization programs for radiology create conflict between hospitals and health plans.
The study's authors say stakeholders are looking for new ways to increase coverage and access, manage costs and improve the quality of care. The goal of the survey, they said, was to find ways to improve processes, enhance patient satisfaction and reduce costs.
The study found that national plans including Cigna, Aetna and United Healthcare generally did not score as well as local plans.
It also found that Blue Cross Blue Shield was used most frequently in the hospitals surveyed, but did not score highly on measures related to utilization management for surgical admissions. On the other hand, Health New England, used by a much smaller sample of those surveyed, had the best scores on these measures.
On utilization management for psychiatric services, Blue Cross Blue Shield scored very well, the study found.
"While numerous efforts are under way to reduce clinical variation and thus eliminate waste, reduce over- and under-treatment and avoid medical errors, this new report highlights a less publicized opportunity to curb costs by continuing to streamline and simplify many of the administrative processes built into health plans' relationships with healthcare providers," said Lynn Nicholas, the MHA's president and CEO. "The survey findings show that variation among health plans is a major cost driver. When administrative processes can be simplified and made more efficient, cost savings and enhanced patient and provider satisfaction can be the win-win result."
Opportunities identified by the MHA report for health plans to improve and simplify administrative processes include:
- Enhancing radiology management programs so payers are using consistent, evidence-based guidelines, approvals are given more quickly for necessary diagnostic procedures, and inappropriate denials are minimized or eliminated;
- Adjudicating claims correctly the first time so that hospitals are paid accurately on a more timely basis – which, in turn, will help bolster hospitals' fragile financial conditions;
- Regularly updating and disseminating evidence-based clinical guidelines to help foster cost-effective, quality care;
- Giving providers better opportunities to review and verify information to be used in health plan "tiering" programs for physicians or procedures;
- And improving education for health plan members about their specific benefits and obligations so they can be better-informed healthcare consumers.