Although insurer physician ranking plans are not currently in place in every state or market, a number of large national health plans such as UnitedHealth Care and Aetna will be rolling out their quality designation and grading programs this spring and simultaneously sending notifications to physicians regarding opportunities to appeal their rating(s). The Academy is taking this time to encourage affected members to challenge inappropriate insurer ratings.
Though challenging a rating can consume a significant amount of time, physicians who feel strongly enough should first ask for the records associated with their rating, specifically the "drill-down" data that identifies individual patients. Once physicians have obtained the data the insurer is using to make the rating, reviewed it, and gathered their own data if it will refute the rating, the next step is to follow the specific procedure outlined by the insurer for an appeal.
Regardless of whether a physician is unhappy or satisfied with his or her rating, the Academy believes it may be beneficial for physicians to educate their patients about physician profiling. Specifically, let your patients know that you plan to appeal inappropriate rankings.
View the Academy’s Position on the Principles of Physician Profiling.
The American Medical Association (AMA) also recently released a helpful article on this topic.