Joshua D. Gottlieb (
Adam Hale Shapiro is a research advisor at the Federal Reserve Bank of San Francisco, in California.
Health Aff (Millwood). 2018 Apr;37(4):619-626. doi: 10.1377/hlthaff.2017.1325.
The administrative costs of providing health insurance in the US are very high, but their determinants are poorly understood. We advance the nascent literature in this field by developing new measures of billing complexity for physician care across insurers and over time, and by estimating them using a large sample of detailed insurance "remittance data" for the period 2013-15. We found dramatic variation across different types of insurance. Fee-for-service Medicaid is the most challenging type of insurer to bill, with a claim denial rate that is 17.8 percentage points higher than that for fee-for-service Medicare. The denial rate for Medicaid managed care was 6 percentage points higher than that for fee-for-service Medicare, while the rate for private insurance appeared similar to that of Medicare Advantage. Based on conservative assumptions, we estimated that the health care sector deals with $11 billion in challenged revenue annually, but this number could be as high as $54 billion. These costs have significant implications for analyses of health insurance reforms.
美国提供医疗保险的行政成本非常高，但人们对其决定因素知之甚少。我们通过为医生护理制定新的计费复杂性衡量标准，并使用 2013-15 年期间大量详细的保险“汇款数据”对其进行估计，从而推进了这一领域的新兴文献。我们发现不同类型的保险之间存在巨大差异。按服务收费的医疗补助是最具挑战性的保险类型，其拒付率比按服务收费的医疗保险高出 17.8 个百分点。医疗补助管理式医疗的拒付率比按服务收费的医疗保险高出 6 个百分点，而私人保险的拒付率与医疗保险优势计划相似。根据保守假设，我们估计医疗保健部门每年处理 110 亿美元的有争议收入，但这个数字可能高达 540 亿美元。这些成本对医疗保险改革的分析有重大影响。
