Insurer Ratings Report 2011

Doctors Rate Best & Worst Payers

• Survey fielded to 307,000 US physicians

• Total respondents: 10,214 US physicians

• United States was divided into 9 geographic regions to account for differing insurance companies by region

• Fieldwork conducted by Medscape from 9/23/11 to 11/7/11

• Data collected via third-party online survey collection site

Picking a favorite insurer is not easy when so many physicians told us they find almost all payers to be problematic at times. Still, a number of factors make some insurers rise above the others. The nation's largest insurers scored highest. That "honor" is somewhat mitigated, however, because the same companies also show up on physicians' worst insurer list. A Blues plan was named one of the best and is a major payer in nearly all geographic regions. Of those physicians who named a favorite, 29% say a Blues plan is their best insurer.

Three in 10 physicians said they do not know which plan is best. Many doctors are employees and earn a straight salary or work in practices where administrative staff handle most insurance issues.

*Percentages include those respondents who provided a specific answer

Blues plans scored the highest in every one of the 32 specialties surveyed. This ranged from 36% of pulmonary medicine specialists to 14% of HIV/AIDS specialists choosing Blues plans as the best payers. Primary care physicians also said Blues plans were their best insurers: 29% of family physicians and internists said a Blues plan is their choice for best insurer. United Healthcare was the number-2 choice of family physicians (9%), internists (10%), and obstetrician/gynecologists (11%), whereas Aetna was the second choice among pediatricians (10%).

Aetna was also the number-2 choice of gastroenterologists (15%), general surgeons (11%), ophthalmologists (10%), orthopaedic surgeons (8%), plastic surgeons (11%), and urologists (13%).

*Percentages include those respondents who provided a specific answer

Each region of the country may be served by as many as 50 local insurers. Some are small compared with national plans but others may be dominant players in their respective markets, such as Harvard Pilgrim Health Care in the Northeast.

In all regions, Blues plans and Aetna were ranked as the top insurers by physicians. Kaiser Foundation Health Plans, available in 9 states and Washington, DC, scored in the top 3 best insurers among nephrologists (9%) and emergency physicians (9%) and in the top 5 among critical care physicians (8%), anesthesiologists (4%), and other specialists.

Northeast: Maine, New Hampshire, Massachusetts, New York, Rhode Island, Vermont, Connecticut

Mid-Atlantic: Pennsylvania, New Jersey, Delaware, Maryland, Virginia, West Virginia, North Carolina

Southeast: Kentucky, Tennessee, South Carolina, Georgia, Florida, Alabama, Mississippi, Louisiana

Great Lakes: Ohio, Michigan, Indiana, Illinois, Wisconsin, Minnesota

North Central: Iowa, Missouri, Kansas, Nebraska, South Dakota, North Dakota

Northwest: Montana, Wyoming, Idaho, Washington, Oregon, Alaska

South Central: Texas; Arkansas, Oklahoma

Southwest: New Mexico, Colorado, Utah, Nevada, Arizona

West: California, Hawaii

Medscape asked, "What factors were the most important to your having a positive opinion of an insurer?" Clearly, physicians focus on the financial bottom line when evaluating insurers. A majority of physicians (54%) said amount of payment is the most important factor in having a positive opinion about a health plan. However, "easy to do business with" and "frequency of denials" also were important to more than a quarter of physicians.

Insurers often talk about being easy to do business with, having fewer claims denials, and paying more quickly. Approximately 15% of physicians said the top factor is whether the insurer is easy to do business with, whereas 13% ranked frequency of denials as being crucial. Physicians are willing to wait a little longer for reimbursement if the reimbursement is higher.

Nationwide, respondents noted that Blues plans pay noticeably faster than all other insurers. One in 5 doctors said a Blues plan was the speediest payer. In second position -- but significantly lower -- were United Healthcare and Aetna at 7%. On a regional basis, physicians in the Northwest (18%) said Absolute Total Care is the fastest payer followed by Humana at 7%.

Physicians in the South Central, Southeast, Southwest, and the West listed Humana as number 1 for quick reimbursements. One quarter of doctors cited a smaller regional insurer as the speediest payer. Four in 10 doctors nationwide said they do not know which insurer is best. That is likely because many physicians are either employed or work in practices where the administrative staff handle insurance matters.

*Percentages include those respondents who provided a specific answer

Doctors considered not only their current insurers, but also those they previously participated with. United Healthcare had the dubious distinction of being voted the worst insurer nationwide in the eyes of the highest percentage of physicians (14%), followed by Blues plans (10%), Aetna (8%), and Cigna and Humana (both at 6%). These plans also ranked highest as best insurers by a plurality of physicians. That is not necessarily contradictory because the major payers are most likely to win praise and complaints as a result of the volume of their dealings with doctors.

There was less fervor to name some insurers as the worst than there was enthusiasm to name them the best. For example, the Blues plans got 28% of votes for best insurer but only 10% of votes for worst.

*Percentages include those respondents who provided a specific answer

Almost 90% of the more than 4700 responses were negative about insurers, ranging from mild frustration to fury, mostly about denials of payment and difficulty getting straight answers from health plans.

Many physicians said that they have had so many bad experiences with insurers, it was hard to cite just one. "Insurers dictate bad medicine and place patients at risk," several doctors said. "One refuses to pay an admission on a patient who presents to the ED with chest pain. One patient subsequently was sent for catheterization and ended up having a bypass." Another doctor said an insurer refused to authorize a colonoscopy for a patient with rectal bleeding and a hard palpable mass until he first did a flexible sigmoidoscopy. "That's a useless test, only adding to the cost of treatment," he said. "Then they refused to reimburse for the flexible sigmoidoscopy that they had demanded."

Getting claims kicked back is the bane of medical practices. Denial of claims easily ranks as the biggest frustration physicians have with insurers. The major complaint: Insurers routinely deny legitimate claims as a stalling tactic. "I was denied payment as out of network," one physician said. "When it was confirmed that I was indeed in network, I was denied payment because of a late submission, totally caused by the insurer's delaying tactics." Other doctors note that insurers often claim they never received documentation despite registered mail and FedEx® receipts proving otherwise.

United Healthcare was listed as the company with the greatest frequency of denials by 12% of physicians nationwide, providing supporting evidence for doctors ranking it as their worst insurer. Blues plans at 11% and Aetna at 7% were the next highest in claims denials nationwide.

*Percentages include those respondents who provided a specific answer

Faced with low and slow reimbursements plus hassles over claims denials and preauthorization, physicians drop insurers that cause the most frustration. Just under a quarter (24%) of respondents have dropped an insurer in the last 2 years.

Most practice management consultants recommend that practices evaluate their payer mix and drop the worst companies each year. That is not always possible, depending on each market. Of the physicians who dropped an insurer, 10% of physicians nationwide say they dropped a Blues plan over the past 2 years, followed by 7% for United Healthcare, Cigna, and Aetna. Almost half of surveyed physicians dropped a smaller regional provider.

"In a perfect world, it makes sense to do that if you can," says Tommy Bohannon, vice president for hospital-based recruiting for Merritt Hawkins. "Physicians don't always have that option. It depends on the market and your patient base."

*Percentages include those respondents who provided a specific answer

The number of insurance companies physicians participate with in a given year can vary widely. Most practices try to cover all bases and be accessible to patients enrolled in most plans. Almost a third of all physicians nationwide participate with 6 to 10 insurers. Nearly 20% participate with at least 21 plans.

There is little variation in the number of insurers based on region of the country. However, physicians in the West are somewhat more likely to contract with fewer than 5 insurers than their colleagues across the rest of the country.

Reflecting their market penetration in nearly every state, Blues plans are easily the leading payer by total dollars collected. Almost one third of physicians said a Blues plan was their top payer, followed by United Healthcare at 9% and Aetna at 5%. Approximately one quarter of the physicians surveyed said they didn't know who their leading payer was.

Blues plans were the top payer in every region of the country except the Southwest, where 23% of physicians said United Healthcare was their leading payer. The widest gap is in the Mid-Atlantic where 49% of doctors say a Blues plan is number 1, followed by 7% who listed Aetna as their top payer.

*Percentages include those respondents who provided a specific answer

By a wide margin, Blues plans are the leading insurer based on the number of patient visits. Roughly 30% of physicians nationwide listed a Blues plan as number 1, followed by United Healthcare at 9% and Aetna at 4%. That market dominance exists in nearly every region of the country. The disparity between Blues plans and other insurers is obvious; it is greatest in the Mid-Atlantic states, where 48% of doctors say a Blues plan is the leading insurer followed by 6% for Aetna and 5% for United Healthcare.

The dominance of Blues plans was not completely universal, however. The Southwest is the only region where the Blues plans are not the top insurer. In the Southwest, United Healthcare is number 1, with 22% of physicians, followed by the Blues plans at 12%.

*Percentages include those respondents who provided a specific answer

Almost half of physician respondents negotiate their agreements directly with insurers. This reflects the large number of physicians in private practice, which is still the dominant mode of practice, although employment in a practice is becoming more common. Another third of respondents are employed and work in a hospital, which negotiates the insurer agreement.

The vast majority of physicians receive reimbursement at least equivalent to Medicare rates from their best payers. One in 5 doctors receives at least 110% of Medicare rates and 9% of doctors receive less than Medicare rates. There are few significant differences based on region, except that only 5% of Northwestern doctors receive less than Medicare.

Those specialists who receive more than 110% of Medicare rates are anesthesiologists and orthopaedists(38%), plastic surgeons (36%), gastroenterologists (33%), and general surgeons (32%). Physicians most likely to receive less than Medicare rates include dermatologists (15%), HIV/AIDS specialists (14%), and endocrinologists and cardiologists (13%).

*Percentages include those respondents who provided a specific answer

CPT code 99203 is the bread and butter of primary care and many other practices. It is the most common code physicians use for a new patient office visit. Of physicians who knew what their reimbursement was, 20% received between $75 and $125 for the visit. A fortunate 8% bring in more than $150 on average for that code.

"Wide variations in payment are the result of where doctors live," says Tommy Bohannon. "Plans base payments on percentage of Medicare; some may be 100%, others 130%, etcetera. Medicare has geographic rates based on doctors' expenses. So a doctor in San Francisco will get more for the same CPT code as a doctor in Kentucky, but they should net the same since the San Francisco doctor's expenses are higher."

*Percentages include those respondents who provided a specific answer

The largest percentage of doctors who knew their payment amount for CPT code 99213 are making from $40 to $70. That reimbursement is by no means universal, however. Almost as many are bringing in from $71 to $100, and a smaller percentage are making over $100. That is as much as 3 times the amount for each patient with the lowest reimbursement amount, < $40. These findings indicate that the lower-reimbursement doctors could need to see 3 times as many patients to earn the same revenue.

Practice and business expert Judy Aburmishan notes the large variations are probably the result of "in network vs out of network and the version of plan they are with. There are probably regional variations based on the competition in a market as well. For examples, insurers pay physicians in Chicago much less than they pay them in rural Illinois because there are more doctors competing for patients."

*Percentages include those respondents who provided a specific answer

Of physicians who knew their payment amount, 20% received less than $260 for CPT code 99223 for a high-level hospital admission.

Almost three quarters (72%) of respondents did not know the reimbursement for this code, probably reflecting that billing is handled by hospital or other administrators. To bill for code 99223, requirements are history of present illness, medical history, review of systems, complete physical examination, high-complexity medical decision-making (including 2 of these 3 components diagnosis, data, concepts).

*Percentages include those respondents who provided a specific answer

Although some physicians are resigned to accepting whatever the insurer pays, a majority urge fighting back with persistence. "When you get a denial, don't waste your time with the 1-800 line. Demand to speak to the medical director," one doctor says. "Involve the patient's human resources department to bring pressure on the plan. Let the plan know that you will notify your state insurance department about unjust denials."

Óther advice: Review your claims and contracts at least quarterly to see whether the insurers are reimbursing at the agreed on rates. They will often lower the payments, and your office manager may not be aware of the contracted amounts. "Just keep hitting them with documentation and always ask for a supervisor," says one doctor.

Insurer Ratings Report: 2011

Editorial Director:
Leslie Kane, MA
Medscape Business of Medicine

Captions:
Mark Crane, Freelance Writer
Brick, NJ

See also:
How Doctors Get More From Insurers (Despite Anger and Frustration)

Physician Compensation Report: 2011