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1 weights& measures What View Measures Weight What it Measures Days in A/R 25% Average length of time to receive payment (measured from the date of charge entry to the date the remittance is posted). Financial Performance 60% First-Pass Resolution Rate Collection Burden 25% 10% Percent of claims successfully resolved (paid or transferred to patient responsibility) on the initial submission. Percent of charges transferred from the primary insurer to the next-responsible party. Includes coinsurance, deductibles, and other transfers (such as noncovered services), but not copayments or realtime adjudication because those should be known at the time of service. Administrative Performance 20% Denial Rate 20% Percent of claims requiring back-end rework (includes pended and denied claims). Transaction Efficiency 20% ERA Transparency Eligibility Accuracy 10% 10% Percent of electronic remittance advice (835) denial messages with actionable explanations and clear next steps. Reflects how well the payer has adopted the HIPAA 835 standard code set. Correlation of eligibility response to adjudication outcome. Measures how well a payer s eligibility transaction predicts the outcome of a claim.
2 Entities included in corporate parent overall performance United health group: Cigna: HCSC: Rank Americhoice, Oxford HP, Pacificare, United HC of River Valley, United Healthcare Cigna/Healthsource, GreatWest BCBS-IL, BCBS-NM, BCBS-OK, and BCBS-TX n a t i o n a l WellPoint: Medicare-B: BCBS-CO, BCBS-CT, BCBS-GA, BCBS-IN, BCBS-KY, BCBS-NY Empire, BCBS-OH, BCBS-VA, Blue Cross-CA, Unicare Comprised of 29 states plus Medicare Railroad 1 Aetna % % 3 5.1% % % 3 2 Humana % % 4 5.6% % % 1 3 United Health Group % % 2 5.3% % % 2 4 Cigna % % 6 4.0% % % 5 5 HCSC % % 8 8.4% % % 4 6 Wellpoint % % 5 6.3% % % 6 7 Medicare-B % % 7 6.2% % % 8 8 Champus-Tricare % 8 9.5% 1 6.2% % % 7 Rank B l u e s 1 BCBS-RI % 2 4.2% 2 3.4% % % 5 2 BCBS-MA % 8 7.0% 3 6.3% % % 1 3 BCBS-OH % % % % % 9 4 BCBS-PA Capital Blue Cross % % % % % 5 5 BCBS-IL % % % % % 4 6 BCBS-NM % % % % % 24 7 BCBS-WA Premera % % % % % 22 8 BCBS-IN % % % % % 15 9 BCBS-PA Highmark Blue Shield % % 9 8.8% % % BCBS-TX % % % % % 3 11 BCBS-SC % % % % % BCBS-CO % % % % % BCBS-GA % % % % % BCBS-FL % % % % % 7 15 BCBS-VA % % % % % BCBS-AZ % % % % % BCBS-NC % % % % % BCBS-CT % % 6 5.2% % % BCBS-OK % % % % % 2 20 BCBS-KY % % % % % BCBS-WA Regence % % % % % BCBS-AL % % 7 8.6% % % BCBS-MI % % % % % Blue Cross-CA % % % % % BCBS-MS % % % % % BCBS-PA Highmark BCBS % % % % % Keystone Health Plan East % % 1 9.7% % % BCBS-AR % % % % % 7 29 BCBS-NJ % % % % % BCBS-NY Empire % % % % % BCBS-TN % % % % % BCBS-LA % % % % % BCBS-PA Independence BC % % 4 4.0% % % Blue Shield-CA % % % % % BCBS-DC % % % % % BCBS-MD % % % % % BCBS-OR % % % % % 37
3 m e d i c a r e 1 Medicare B-WA % % % % % 1 2 Medicare B-OR % % % % % 9 3 Medicare B-GA % % 5 3.1% % % 12 4 Medicare B-CT % % 2 4.2% % % 26 5 Medicare B-NC % % % % % 32 6 Medicare B-IL % % % % % 17 7 Medicare B-CA Northern % % % % % 5 8 Medicare B-OH % % % % % 27 9 Medicare B-AR % % 6 5.0% % % Medicare B-TN % % % % % Medicare B-VA % % % % % 5 12 Medicare B-NJ % % 1 5.1% % % Medicare B-MI % % % % % Medicare B-MA % % % % % 2 15 Medicare B-IN % % % % % Medicare B-PA % % % % % Medicare B-SC % % % % % Medicare B-LA % % % % % Medicare B-KY % % % % % Medicare B-AZ % % % % % 2 21 Medicare B-CO % % 8 4.6% % % 5 22 Medicare B-NY Upstate % % 3 5.3% % % 9 23 Medicare B-MS % % % % % Medicare B-AL % % % % % Medicare B-TX % % % % % Medicare B-CA Southern % % 6 8.6% % % Medicare B-OK % % % % % 9 28 Medicare B-NY Empire % % 8 9.1% % % 8 29 Medicare B-MD % % % % % Medicare B-FL % % % % % Medicare B-NM % % % % % 4 32 Medicare B-Railroad Medicare % % % % % 16 Rank m e d i c a i d 1 Medicaid-IL % 1 3.2% % % % 4 2 Medicaid-LA % 7 0.9% % % % 2 3 Medicaid-KY % 2 4.0% % % % 10 4 Medicaid-OH % 4 4.9% % % % 18 5 Medicaid-NC % 4 2.1% % % % 8 6 Medicaid-NY % 8 3.0% % % % 7 7 Medicaid-VA % % % % % 14 8 Medicaid-AR % % % % % 1 9 Medicaid-MS % % % % % 3 10 Medicaid-FL % 6 3.4% % % % Medicaid-AL % 9 2.2% % % % 5 12 Medicaid-MA % % % % % 8 13 Medicaid-GA % % % % % Medicaid-NJ % % % % % 6 15 Medicaid-SC % % % % % Medicaid-TX % % % % % Medicaid-PA % % % % % Medicaid-OK % % % % % Medi-Cal CA % % % 5 6.4% % 16
4 N o r t h e a s t 1 BCBS-RI % 2 4.2% % % % 14 2 Aetna & Aetna-US Healthcare % 3 9.2% % % % 9 3 BCBS-MA % 7 7.0% % % % 8 4 BCBS-PA Capital Blue Cross % % % % % 14 5 United Healthcare % % % % % 7 6 Medicare B-CT % % % % % 30 7 Cigna-HealthSource % % % % % 17 8 Medicare B-NJ % % % % % 34 9 NHP-MA % % 3 4.4% % % 3 10 Medicare B-MA % % % % % Medicare B-PA % % % % % BCBS-PA Highmark Blue Shield % % % % % Medicare B-NY Upstate % % % % % CDPHP (NY) % % 9 5.7% % % Tufts % % % % % 1 16 BCBS-CT % 8 9.0% % % % Medicare B-NY Empire % % % % % Unicare % % % % % Harvard Pilgrim % % % % % 6 20 Oxford HP % % % % % 5 21 Healthfirst NY & NJ % % 5 7.3% % % Keystone Health Plan East % % 8 9.6% % % BCBS-PA Highmark BCBS % % % % % Health Net-NE % % % % % BCBS-NJ % % % % % BCBS-NY Empire % % % % % MVP Health Plan of NY % % % % % BCBS-PA Independence BC % % % % % Network Health (MA) % % 2 4.9% % % 4 30 Boston Medical Ctr-Health Net % % % % % 2 31 Fallon % % % % % Group Health Inc (GHI) % % % % % HIP of Greater NY % % % % % Americhoice % % 4 8.8% % % Fidelis Care NY % % % % % Medicaid-NY % % % % % Medicaid-MA % % % % % Medicaid-NJ % % % % % Medicaid-PA % % % % % Horizon NJ Health % % % % % 40
5 S o u t h 1 United Healthcare % % % % % 4 2 Aetna & Aetna-US Healthcare % % % % % 6 3 Humana % % % % % 4 4 Medicare B-GA % % % % % 27 5 Cigna-HealthSource % % % % % 14 6 Medicare B-NC % % % % % 42 7 Medicare B-AR % % % % % 34 8 Medicare B-TN % % % % % 32 9 Medicare B-VA % % % % % Southern Health Services % % % % % 9 11 Champus-Tricare PGBA % % % % % Medicare B-SC % % % % % Medicare B-LA % % % % % BCBS-SC % % % % % BCBS-GA % % % % % Amerigroup-GA % % % % % BCBS-FL % % % % % BCBS-VA % % % % % BCBS-NC % % % % % Medicare B-MS % % % % % Medicare B-AL % % % % % BCBS-OK % % % % % 7 23 Avmed % % % 18 NA NA 93.0% Medicare B-OK % % % % % United HC of River Valley % % % % % Medicare B-MD % % % % % BCBS-AL % % % % % Medicare B-FL % % % % % BCBS-MS % % % % % BCBS-AR % % % % % Medicare B-Railroad Medicare % % % % % BCBS-TN % % % % % BCBS-LA % % % % % Medicaid-LA % % % % % 2 35 BCBS-DC % % % % % BCBS-MD % % % % % Medicaid-NC % % % % % Medicaid-VA % % % % % Medicaid-AR % % % % % 1 40 Medicaid-MS % % % % % 3 41 Medicaid-FL % % % % % Medicaid-AL % % % % % 8 43 Medicaid-GA % % % % % Medicaid-SC % % % % % Medicaid-OK % % % % % 45
6 M i d w e s t 1 Aetna & Aetna-US Healthcare % % 9 4.2% % % 4 2 United Healthcare % % % % % 1 3 Humana % % % % % 3 4 HealthPartners % % % % % 11 5 BCBS-OH % % % % % 8 6 Medicare B-IL % % % % % 16 7 BCBS-IL % % % % % 7 8 Medicare B-OH % % % % % 21 9 BCBS-IN % % % % % Medicare B-MI % % % % % Medical Mutual Of Ohio % % % % % Medicare B-IN % % % % % Medicare B-KY % % % % % Cigna-HealthSource % % % % % Molina Healthcare of Ohio % % 4 7.2% 18 NA NA 97.2% 6 16 Summacare % % 8 4.8% 6 NA NA 84.9% Medica % % % % % 9 18 BCBS-KY % % % % % Caresource % % % % % 5 20 BCBS-MI % % % % % Buckeye Community Health Plan % % 1 7.0% 16 NA NA 92.0% Medicare B-Railroad Medicare % % % % % Unison Health Plan % % 3 9.8% % % Medicaid-IL % % % % % 2 25 Medicaid-KY % % % % % Medicaid-OH % % % % % 26
7 w e s t 1 Humana % % % % % 1 1 United Healthcare % % % % % 3 3 Aetna & Aetna-US Healthcare % % % % % 4 4 Medicare B-WA % % % % % 10 5 Medicare B-OR % % % % % 16 6 Champus-Tricare WPS % 9 9.3% 9 4.1% % % 20 7 BCBS-NM % % % % % 19 8 BCBS-WA Premera % % % % % 13 9 Medicare B-CA Northern % % % % % Cigna-HealthSource % % % % % 8 11 Providence Health Plan % % % % % 9 12 Medicare B-AZ % % % % % BCBS-TX % % % % % 5 13 Medicare B-CO % % % % % Health Net-AZ % % 7 5.0% % % BCBS-CO % % % % % BCBS-AZ % % % % % Medicare B-TX % % % % % Medicare B-CA Southern % % % % % BCBS-WA Regence % % % % % Molina Healthcare of NM % % 5 8.0% 20 NA NA 96.3% 6 22 Blue Cross-CA % % % % % Pacificare % % 3 3.9% % % Medicare B-NM % % % % % Mercy Care Plan of Arizona % % 8 8.7% 24 NA NA 78.3% Blue Shield-CA % % % % % BCBS-OR % % % % % Great West Healthcare % % % % % Health Net-CA-OR % % % % % Amerigroup-TX % % % % % Superior Health Plan % % % % % 2 32 Medicaid-TX % % % % % 7 33 Medi-Cal CA % % % % % 24
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