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athenahealth 2013 PayerView Report: Payers slow to go digital, Medicaid underperforms again, ICD-10 cash flow disruption

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WATERTOWN, MA – June 26, 2013 – athenahealth, Inc. (NASDAQ: ATHN), a leading provider of cloud-based services for electronic health record (EHR), practice management and care coordination, today unveiled the 2013 PayerViewReport, an annual quantitative report that uses athenahealth’s cloud-based data, spanning a national network of more than 40,000 health care providers, to deliver insight into the provider-payer relationship.

PayerView ranks both government and commercial payers in areas of financial performance, administrative performance, and transaction efficacy to provide an objective, quantitative measure of how easy or difficult it is for providers to work with certain payers. Rankings are derived from athenahealth’s aggregated, national data set of more than 40,000 providers, 83 million charge lines and $15 billion in charges. The 2013 report reveals five major trends:

#1: Despite modest improvements, Medicaid continues to underperform
•    As it has for the past several years, Medicaid continues to underperform on key metricssuch as Days in Accounts Receivable (DAR), which measures the average number of days it takes a practice to collect on payments.As millions more payments are processed through the Medicaid Expansion, going into effect in January 2014 as part of the Affordable Care Act (ACA), the inability of Medicaid to process payments efficiently could have dire consequences for provider cash flow.

#2: ANSI 5010 conversion challenges may point to upcoming ICD-10 related disruption
•    ANSI 5010, a federally required electronic transaction standards update that went into effect in January 2012 and is a precursor to the ICD-10 medical coding transition, requires providers to submit claims in a new data format. PayerView shows that in the first quarter of 2012, coinciding with the ANSI 5010 transition date, the percent of claims successfully resolved on initial submission (e.g., paid or transferred to patient responsibility) was down. These conversion challenges with ANSI 5010 could be an early indicator of future breakdowns in the processing and payment of claims as the ICD-10 October 2014 deadline approaches.

#3: Providers struggle to collect full reimbursement
•    Many payers performed worse than the median 95 percent benefit accuracy, including six payers that only returned correct co-pay information less than 50 percent of the time. Given that co-pay information from payers isoften inaccurate and co-pays continue to increase for certain services, the burden on providers to monitor and seek out timely and accurate information on patient payment responsibility remains high.

#4: As reimbursement models shift, some payers seem to be staying put
•    Several payers did not fare well in the area of incentive program administrative burden and transparency, with just 17 percent of payers receiving the highest score and 40 percent not having any clear information available on pay-for-performanceprograms for participation by independent physicians.

#5: Payers are slow to go digital with some transactions
•    Electronic enrollment continues to be difficult for providers across most payers, with payers still requiring a staggering 65 percent of transactions to be conducted by fax or mail.

“Collecting co-pays, challenging claims denials, reviewing billing performance – are all tasks that continue to challenge me and my staff, but are necessary when it comes to ensuring my practice is making, not losing, money,” said Dr. John Kulin, CEO and medical director of NJ-based The Urgent Care Group, PA. “athenahealth’s PayerView report tells a story, from thousands of providers across the country, about the sticking points of working with payers and getting reimbursed. The insight I glean from PayerView allows me to benchmark challenges and successes against other practices, prepare for future profitability, and ensure my practice thrives in light of the upcoming ICD-10 conversion and shifting reimbursement models.”

About half of the payers analyzed—68 out of 138—improved on key performance metrics; payer rankings can be viewed online here, by downloading the 2013 PayerView report. Most notable, Humana took over the overall top spot as #1 payer for 2013.

Bruce Perkins, president of Humana’s Healthcare Services segment, said: “Humana is proud to be named as PayerView’s number one national payer. We have always been committed to our provider relationships and are excited that our commitment and our integrated care delivery approach are paying off with positive results. Humana’s ranking proves that the cornerstone of our integrated care delivery model—enriched data integration among providers, clinicians, and caregivers—is not only working for providers, but for the entire healthcare system by creating a more effective and more efficient, member-focused model of care.”

“With changing reimbursement models entering the scene and the influx of millions of new Medicare patients looking for care, there’s no slowing of challenges for both providers and payers,” said Todd Rothenhaus, chief medical officer, athenahealth. “Because of these changing dynamics in health care, we explored a few new metrics in this year’s PayerView report. We looked at ease of access to information on pay-for-performance programs, delivery of accurate co-pay amounts, and provider enrollment efficiency. While we did not include the new evaluations areas as part of payers’ overall rankings, we are sharing the results and calling on payers to step up in areas like electronic enrollment and benefit accuracy to ensure providers get paid faster and more efficiently.”

For more information on athenahealth’s cloud-based services, which enable real-time visibility into a unique data asset that makes PayerView possible, visit www.athenahealth.com.


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