Medicare Compliance & Reimbursement

Physicians received no payment at all on nearly 23 percent of claims submitted to commercial payers. The American Medical Association (AMA) released its fourth annual National Health Insurer Report Card (NHIRC) last month, and the findings don't paint a pretty picture. According to the AMA, commercial payers show an average claims processing error rate of 19.3 percent. That represents a two percent increase over last year.

"A 20 percent error rate among health insurers represents an intolerable level of inefficiency that wastes an estimated $17 billion annually," said AMA Board Member Barbara L. McAneny, M.D., in the AMA press release. "Health insurers must put more effort into paying claims correctly the first time to save precious health care dollars and reduce unnecessary administrative tasks that take time and resources away from patient care." UnitedHealthcare was the only payer included in the 2011 report card that showed an improvement in claims-processing accuracy. UnitedHealthcare ranked first in the list of seven leading commercial payers with an accuracy rating of 90.23 percent. The worst score -- 61.05 percent -- went to Anthem Blue Cross Blue Shield.

Additionally: The report card also showed that physicians received no payment at all on nearly 23 percent of claims you submitted to commercial payers. "There are many reasons a legitimate claim may go unpaid by an insurer," the AMA press release indicates. "Claims may be denied, edited or deferred to patients. During Feb. and March of this year, the most common reason insurers didn't issue a payment was due to deductible requirements that shift payment responsibility to patients until a dollar limit is exceeded. Real-time claims processing would save time and money."

Good news: There were lower denial rates for many of the payers included in the report, including Aetna, Anthem Blue Cross Blue Shield, Health Care Service Corporation and UnitedHealthcare. Cigna continues to have the lowest denial rate -- .68 percent this year.

Plus, the report card shows that two payers -- Cigna and Humana -- cut their median claims response time in half during the last four years.

To read the complete AMA report, visit www.ama-assn.org/go/reportcard.

You'll no longer have to wait for case-by-case determinations on whether your MAC will cover Provenge® for your seriously ill prostate cancer patients.

CMS has issued a final coverage decision indicating that it will cover cellular immunotherapy, or sipuleucel-T (brand name Provenge®) effective immediately. CMS will cover Provenge® for FDA-approved uses including treating asymptomatic or minimally symptomatic metastatic castrate resistant prostate cancer. Previously, the treatment was covered only on a case-by-case basis by local contractors.

Ever since CMS introduced its PQRS program, many practices have told CMS that they've faced difficulty understanding the intricacies of the system, with some complaining that they've been hesitant to participate because it's too confusing.

But CMS aims to quell those concerns with three new educational resources about the program. The first, a PQRS Claims Registry Fact Sheet, offers guidance on claims-based and registry-based reporting, and shows you the steps you should take to get the lowdown on PQRS.

The second document discusses how to participate in PQRS's Preventive Care Measures Group, and the third shows you the Reporting Periods for 2011.

To gain access to the documents, visit www.cms.gov/PQRS and select the "educational resources tab." Then click "downloads" and select the appropriate publication.