AMA -20 percent of medical claims calculated wrong


The American Medical Association (AMA) is the largest association of physicians and medical students in the United States. Recently AMA has released a study as part of its annual National Health Insurer Report Card (NHIRC) on America’s Health Insurance Plans, which represents the nation’s largest plans. The study examined the strengths and weaknesses of the claims processing systems used by seven of the nation’s largest health insurers.

The National Health Insurer Report Card is the cornerstone of the AMA’s Heal the Claims Process campaign. It was first launched in June 2008 and this is the second year in a row when AMA has released its report card again.

The study reveals that one in five medical claims is processed inaccurately by the nation’s largest health insurers; slowing payments to doctors and causing confusion for consumers. The largest insurers of US are Aetna, Anthem Blue Cross Blue Shield, Cigna Corp., Coventry Health Care, Health Care Service Corp., Humana Inc. and UnitedHealth Group.  

Coventry Health Care Inc. had the most accurate...

claims processing, with 88.41% of all claims processed accurately, followed by Health Care Service Corp. with 87.83% whereas, Anthem
Blue Cross Blue Shield came in last, with a 73.98% accuracy rate.

The AMA report is based on a random sample of about 2 million electronic claims. Dr. Nielsen, AMA mentioned that each insurer uses different methods for processing and paying medical claims as a result it creates confusion and inconsistency in claims processing.  

The inefficient and inconsistent claims process adds as much as $200 billion annually to the health-care system. If it can be corrected to 100% accurate claims, it can save $15 billion the health care system according to AMA.  I see an opportunity for insurance companies or enterprenuers to come up with a common processing system to enhance efficiency.

One Response

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