Private Payer Round-Up, June 2013

In case you missed these — here is a roundup of useful items from health care payment plans’ newsletters and updates, compiled by TMA’s reimbursement specialists.

If you have questions about billing and coding or payer policies, contact the specialists at for help, or call TMA Knowledge Center at (800) 880-7955. TMA members can use the TMA Hassle Factor Log to help resolve insurance-related problems.

New AMA Index Ranks Health Insurers by Administrative Burden 

The American Medical Association unveiled its new Administrative Burden Index (ABI) (PDF) to rank commercial health insurers according to the level of unnecessary cost they contribute to the billing and payment of medical claims. AMA found that administrative tasks associated with avoidable errors, inefficiency, and waste in the medical claims process resulted in an average ABI cost per claim of $2.36 for physicians and insurers. Cigna had the best ABI cost per claim of $1.25, or 47 percent below the commercial insurer average. Health Care Service Corp., which operates Blue Cross and Blue Shield of Texas (BCBSTX),  had the worst ABI cost per claim of $3.32, or 41 percent above the commercial insurer average

AMA also released its National Health Insurer Report Card (PDF), which for the first time examined the portion of health care expenses that patients are responsible for through copays, deductibles, and coinsurance. During February and March 2013, patients paid an average 23.6 percent of the amount that health insurers set for paying physicians.

Read the news release.

Aetna Ranking Reminder 

Be sure to read the Aexcel ranking letter sent to you by Aetna this month. TMA encourages you to appeal your Aetna ranking if you believe it does not comply with a state law. TMA has developed a Physician Ranking Toolkit to help physicians with the appeals process.    


Enhancements to AIM’s clinical appropriateness guidelines — Expect to see changes on June 28, 2013 — based on provider feedback — to AIM Specialty Health’s (AIM’s) clinical appropriateness guidelines for imaging services, including MRI of the lower extremity. These changes will make it more intuitive and efficient for physicians to submit requests for MRI of the knee. If you have questions, contact AIM at (800) 252-2021.  

Source: BCBSTX 

General reminders — Be sure to check out the June 2013 issue of BlueReview (PDF) for news, updates, and reminders, including the following:

  • Billing for noncovered services: If you are a contracted BCBSTX physician, you may collect payment from a covered patient for copays, coinsurance, and deductible amounts, but you may not charge the patient more than the patient share shown on the  provider claim summary or electronic remittance advice If BCBSTX determines a proposed service is not covered, you must inform the patient in writing in advance. This will allow you to bill the patient for the noncovered service rendered. You are never allowed to collect payment from covered patient for identified hospital-acquired conditions and/or serious reportable events.
  • Avoidance of delay in claims pending COB information: BCBSTX reports receiving thousands of claims each month that require unnecessary review for coordination of benefits (COB). What that means to the physician is a possible delay, or even denial of services, pending receipt of the required information from the BCBSTX member. Here are some tips to help prevent claims processing delays when there is only one insurance carrier:  
    • CMS-1500, box 11-d — If there is no secondary insurance carrier, mark the “No” box.
    • Do not place anything in box 9, a through d. This area is reserved for member information for a secondary insurance payer.
    • It is critical that no information appears in box 11-d or in box 9 a-d if there is only one insurance payer.
  • Contracted physicians must file claims: Physicians must file claims for any covered services rendered to a patient enrolled in a BCBSTX health plan. You may collect the full amounts of any deductible, coinsurance, or copayment due and then file the claim with BCBSTX. Arrangements to offer cash discounts to an enrollee in lieu of filing claims with BCBSTX violate the requirements of your physician contract with the payer. Note, however, that under HIPAA, if a patient self-pays for a service in full and directs you to not file a claim with the patient’s insurer, you must comply with that directive and may not file the claim in question. That is, you must comply with HIPAA and not file the claim to BCBSTX.


Not accepting new patients for behavioral health? — If you are a member of Cigna’s behavioral health network, be sure to inform Cigna if your practice is not currently accepting new patients. This will help avoid confusion and unnecessary referrals. You can notify Cigna at Log in to the Provider section, then go to Online Tools & Resources > Profile Update Form to change your status.

If you are not registered for online use, or have forgotten your password, call the Cigna Provider Service Center (800) 926-2273 for help.

Note that the date at which you will no longer be accepting new patients cannot be more than 90 days in the future. If a care manager contacts you about a possible appointment, inform him or her of your unavailability so Cigna may update its records.

Practices accepting new patients but only at a subset of service locations should contact the Cigna Provider Service Center.

Source: Cigna 

New pharmacy benefit manager — Cigna has entered into a 10-year agreement with pharmacy benefit manager (PBM) Catamaran. The deal is expected to bolster Cigna’s drug purchasing power and help lower costs. Catamaran will process claims; procure prescription drug inventory and fulfill orders for Cigna’s home delivery pharmacy operations; and handle retail network contracting.

Cigna expects the full transition to Catamaran to take two to three years. For now, the payer says, it is “business as usual” for physicians:

  • Your contractual relationship, payment, and interaction with Cigna regarding pharmacy benefits will not change.
  • Cigna will maintain all functions that affect how you care for Cigna-covered patients.
  • Cigna will continue to operate Cigna Home Delivery Pharmacy. You can continue to place prescription orders using your current process. Cigna Home Delivery Pharmacy will intake, verifies, and service orders. Catamaran will maintain drug inventory, and package and ship the finished prescriptions under the Cigna name/label.

If you have questions, call Cigna Customer Service at (800) 88Cigna (882-4462).

Source: Cigna (log-in required).

Published June 20, 2013 

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