Association Executive Directors Community

assistance requested - payer performance measures

  • 1.  assistance requested - payer performance measures

    Posted 07-16-2020 10:20
    Many of us struggle with the same problems with an increasingly small set of national payers. To the extent we, as a group, can define, measure and share similar data, I think we can strengthen our ability to inform our states, effectively measure payer performance, and reduce the challenges our members face.

    I'm reaching out to share our experience and data. I'm also asking for your assistance by sharing your experience with data collection on payer performance.

    Maryland has chosen to launch its ASO with a new vendor -- Optum using InfoMC's Incedo product. A year after awarding the contract to Optum, many key parts of the system either do not exist or simply do not function:
    • Incedo has not produced either in their entirety or with reasonable accuracy 999, 277, nor 835 reports to help providers manage their AR. Are these standard reports for the payers in your states? Optum takes the position that these are not standard elements of a claims processing system, so I am particularly interested in hearing any other states' experience with Optum's inclusion of the elements. 
    • Incedo's denial rate of 16% for the claims that make it into their system is cited as positive. Our members' typical claims denial rate is under 2%. Do you have any data on your members' claims denial rate? Bonus points for denial rates in other Optum systems.
    • Incedo's authorization process has taken the time required to submit an auth request from 5-10 minutes to 40-60 minutes per request. Do you have any data on the average time required with your payers to complete auth requests for: (a) outpatient treatment; (b) rehabilitation services; and (c) residential or crisis programs.
    • Due to the complexity of Incedo's system, several of our members have re-directed their resources away from direct care to add back-office FTEs. Have any of you attempted to measure a re-deployment of resources like this? If so, I'd love to hear what worked and what didn't.

    If you're interested, we released a survey of our members' experience with Optum and confidence in Incedo claims processing earlier this week. It is available here.

    Thank you, as always, for your attention and any insights you can offer.

    Shannon Hall
    Executive Director
    Community Behavioral Health Association of Maryland
    Catonsville MD
    410-788-1865 ext 2