Payer Intelligence for Independent Practices

Payer intelligence profiles covering prior authorization requirements, known denial code patterns, prompt pay compliance history, and policy update tracking for UnitedHealthcare, Aetna, Cigna, Humana, Anthem/Elevance, and regional Blue Cross Blue Shield plans. Data sourced from CMS Medicare Advantage data, AMA prior authorization surveys, state insurance department enforcement records, and community-reported payer alerts.

Prior authorization burden: the AMA 2023 Prior Authorization Survey found that 94% of physicians report care delays due to prior auth requirements, and 33% report that prior auth has led to a serious adverse event for a patient. UnitedHealthcare and Cigna consistently rank highest for prior authorization volume in specialty care. Gold-carding exemptions — where high-performing providers are exempted from prior auth for select procedures — are available in a growing number of states by statute.

Prompt pay compliance: state insurance department enforcement data tracks payer violations of state clean-claim payment windows. Medicare Advantage plans are subject to 42 CFR §422.520 (clean claims paid within 30 days for electronic, 60 days for paper). Self-funded ERISA plans are not subject to state prompt pay statutes but must comply with ERISA §503 claim adjudication deadlines: 30 days for pre-service, 60 days for post-service (extendable once with notice).

Denial pattern tracking: denial code frequencies vary by payer and shift when payers update their clinical editing logic, LCD coverage determinations, or prior authorization requirements. BillingBench tracks known denial pattern changes as reported by billing managers and RCM directors through the community payer alerts system.

• Community payer alerts — reported denial pattern changes
• Prompt pay statutes — payment deadlines and interest rates
• Appeal Letter Builder — ERISA and state-cited appeal letters