What We Mean By “Payer”

athenahealth defines “payer” as an organization to which the physician has to submit a claim in order to get paid. This includes a managed care organization, health insurer, military health plan, HMO, preferred provider organization, third party administrator, Medicare/Medicaid plan, and carrier or intermediary to whom physicians submit third party payment claims. Some of these organizations may be forwarding claims to others for actual adjudication, processing, payment or other important steps in the payment process. Since physicians normally cannot bargain for or dictate the terms of these relationships between payers, and since it may be difficult for physicians to track or monitor movement of claims reliably from one payer to another under these relationships, it is our opinion that the physician’s vantage point is valuable, and we have therefore arranged the data to generally reflect “payers” to be those entities where claims are submitted by physicians in the first instance.

What We Mean By “Performance”

All of the data reflected on this site are derived from the experience of athenahealth and its customers using athenahealth’s claims submission, tracking and follow-up services. The data represent experience during the data collection period by and on behalf of athenahealth physician clients in transactions with the payers listed and/or in transactions on the claims submitted to the payers listed. The rankings and data presented do not and are not intended to present or ascribe causes for that experience, and “performance” is intended to refer to measure of observed results when claims were submitted using our services to a payer.

As noted above in the definition of payer, the activity of a given payer may vary depending on the role that it assumes in the claim process; and, PayerView data results for a given payer may be caused in whole or in part by the actions or processes of others, including other payers, with whom or for whom the payer in turn conducts business. Similarly, the measures chosen for performance are affected by time lags, mistakes, processing practices and data quality on the part of the physician practices involved, by athenahealth itself and by third parties who act as intermediaries in the transmission of claims information. In some cases, such intermediaries are specified or approved by the payer; and, in other cases they may be chosen by other intermediaries or by athenahealth and may be outside of payer control. We actively work to identify and to address matters that we or our customers can control that affect these and other measures, and we have adopted processes that differ from others in the industry. The performance metrics experienced with the same payers by other physicians using other services may have differed materially for the data collection period.

The reasons for results on any of the measures reported in this site are likely to be complex, and athenahealth looks forward to working with any payer to identify and eliminate causes of adverse experience in any of the reported categories.

Data Collection Period And Scope

The data reported here on a national and regional basis were based on actual physician activity captured throughout the 2006 calendar year by athenahealth on our system. This involved an analysis of approximately 28 million charge lines. Obviously, more charge lines applied to some payers rather than others, and the number of athenahealth customers submitting to any one payer varied substantially. For inclusion on a national or regional basis, we included only national payers that met a threshold of 120,000 charge lines per year in our system and regional payers with at least 20,000 charge lines per year. We report these data as we have found them in our system under these parameters, and we make no representation and do not assert that the data are statistically relevant for any given payer or for payers as a whole or that they are indicative of anything other than the experience that we have observed.