Physicians and Insurers: Can They Get Along?

Carol Peckham


October 21, 2014

In This Article

How Do Insurers Measure Up to Physician Needs?

When asked on a scale of 1 to 5 which qualities are most important in an insurer, reimbursement topped the scale at 4.7 and ease of doing business and frequency of denials followed (4.4 each). Very few insurers live up to these expectations. In this year's survey, physicians were asked to rank insurers by these qualities from 1 ("very poor") to 5 ("very good"). The responses were revealing. None of the insurers rated over a 4 on any of these qualities.

Insurer Payment Levels

When ranking reimbursement levels, the Blue Plans came in first again but their rating was only 3.0, with Aetna second at only 2.9. No great difference in rating could be observed in general. Medicare and Oxford tied for last at 2.5. The bottom line seems to be that no insurer reimburses at rates that physicians believe are very favorable.


Top Rated Insurers for Reimbursement Rate

Scores for reimbursement rates also varied by state. For example, 29% of physicians in Florida and 26% of those in New York rated Medicare over a 4 in reimbursement rates, while only 13% of Texans gave them these high scores. Of interest, when asked about speed of reimbursements, Blue Plans, as usual, ranked in first place at 3.4 for speed of payments, and contrary to what some might have expected, Medicare came in second at 3.3.

Blue Plans won out on average reimbursement rate, with nearly half (46%) of physicians reporting payments worth 106% or more of Medicare rates. On the low end, only 20% of physicians reported this amount from Oxford Health Plans, and more than a quarter (26%) said they received less than what Medicare paid with Oxford.

About a third of physicians reported insurers paying amounts equal to or only slightly more than Medicare reimbursements. At this time, according to a survey from Catalyst for Payment Reform, 71% of dollars paid by insurers are to specialists and 29% are to PCPs.[4]

When looking at reimbursement by key CPT codes, Blue Plans and Cigna paid the highest ($100) for a new patient office visit (99203), followed very closely by Aetna ($99). Kaiser Foundation paid the least at $75. For an established patient office visit (99213), Blue Plans led at $65, with Aetna and Cigna following at $63. Kaiser was at the bottom of the list at $49. Blue Plans also paid the most ($120) for high-level hospital admissions (99223) and Kaiser paid the least ($98). Medicare and Medicaid were not included in the insurer options for this question, but according to the CMS physician fee schedule search, the Medicare 2014 national rates for these codes are $108 (99203), $73 (99213), and $204 (99223), which are all higher than those reported in this survey for private insurers.[5]

Physicians were also asked to rank the top three insurers by the amount of money they collected. As would be expected, the amount of money correlated with the number of patient visits. Blue Plans, at 60%, which cover over 105 million patients,[6] were in the top spot for both.

Ease of Doing Business

Blue Plans and Aetna also led in ease of doing business, the second most important attribute. But with ratings of 3.2 and 3.1, respectively, they were both only slightly above average. Oxford was at the bottom of the pack at 2.8. Of interest, Medicare came in fourth at 3.1. When looking at how physicians viewed Medicare by state, results varied widely. Over 40% in Florida (43%) and New York (42%) rated it above a 4 in this category, compared with only 23% in Texas.

Denial of Claims

When asked to provide write-in comments about their worst experiences with insurers, denial of claims was the most frequently and intensively described. One internist who responded to this survey said that his insurer denied over 20 claims every month for pre-existing conditions and retracted more than 20 payments per month processed more than a year before. In regard to insurance plans' frequency of denials, contrary to what many people might have expected, Medicare came out on top with a rating of 3.2, followed by Blue Plans at 3.1. Humana fared worst at 2.8, followed by Oxford.


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