AMA Invites Physicians to Share Concerns About Insurers' Physician Profiling Programs

October 31, 2007


United Healthcare is soliciting reviews of its Premium Designation Program, an online rating system for in-network physicians based on United's standards for both quality and efficiency, from New York physicians contracted with United and Oxford products. This move follows a letter issued by the Office of the New York State Attorney General to United and other health insurers stating that programs such as this could be "causing consumer confusion, if not deception."

The AMA strongly encourages physicians in all states to voice their concerns with inaccurate physician profiling systems. To help facilitate your response, the AMA has created an outline of questions about some of the important problems you may encounter with physician profiling programs:

  • Has the insurer provided you with a complete listing of the quality measures that it used to determine your quality rating based upon your specialty? Are these measures appropriate?
  • Were you provided with all of the data that the insurer used to rate your quality of care and/or cost of care (efficiency) prior to publishing it?
  • Do you know the number of cases used by the insurer to determine your rating?
  • Has the insurer provided you with a detailed explanation of the methodology used to rate your performance? Risk adjustment systems are often minimal, and expert opinions indicate that all risk adjustment systems used to profile physicians are woefully inadequate.
  • If the insurer's data did not belong to you or was incorrect, has the insurer reconsidered your rating?
  • Did the insurer respond to your request for a reconsideration of your rating and, if so, did you receive an adequate explanation?
  • If you were not included in the "preferred" network because you did not have enough cases to be profiled, was the insurer willing to consider cases covered by other insurers?

Send a copy of your letter detailing your specific experience to the AMA, either via email or postmarked to the American Medical Association, Physician Practice Advocacy, 515 N. State St., Chicago, IL 60610.