Physicians should appeal their rating in United Healthcare's (UHC) Premium Designation Program (PDP) by January 27 if they believe it is wrong. According to a letter UHC sent December 23, 2008, to its more than 220,000 participating physicians, only appeals received by January 27 are guaranteed to be adjudicated and updated for the scheduled March release of new ratings for physicians in the PDP. Although physicians may appeal their designation status to UHC at any time, successful appeals received after that date may not be reflected in the initial release of new ratings.
To help physicians understand this, the American Medical Association (AMA) is sharing the following question-and-answer e-mail that clarifies important aspects of UHC's PDP and the appeals process.
In UHC's PDP, physicians who pass UHC's quality check are awarded one star in the UHC directory. A second star is added to those who also pass UHC's "efficiency," or lowest cost of care, criteria. Participating physicians who do not pass the quality check are given no stars, and physicians with insufficient data to be rated are so designated. Some two-star physicians may also be eligible for a fee schedule update through the UHC Practice Rewards Program.
The PDP is based on UHC claims data as measured against their physician performance measures for quality. Efficiency is measured using UHC's episode treatment groups, or ETGs, methodology, which is solely based on cost-of-care factors. Like most physician profiling systems, UHC claims that its data is risk adjusted; however, the risk adjustment factors are limited, and the state of the art for this type of risk adjustment is still somewhat primitive. Questionable physician attribution techniques and small sample sizes used to determine ratings (as few as 10 patients' records) also contribute greatly to rating results that are frequently inconsistent with the actual cost and quality of care being delivered.
Because of the unreliable nature of these results, physicians in the PDP, particularly those who were given only one or no stars for their rating, are encouraged to check the data and analyses that were used to create their ratings. By checking the information that was used to create the rating, physicians may find incorrectly attributed patient episodes or treatments that were due to patient preference or other extenuating circumstances. Physicians who find such errors can appeal the rating results and have them corrected before the ratings are ever used or published.
Physicians should access the UnitedHealth Premium® Designation Program and log in using their ID, which appears on the letter they received from UHC announcing their rating. Physicians who do not have their copy of that letter, experience difficulty with the Web site or do not understand their data are asked to contact UHC at (866) 270-5588. Across the top of the UHC home page are six tabs: Review Report, Reading the Report, Methodology, Reconsideration Process, Frequently Asked Questions and Hospital Comparison Program. These tabs contain the information needed for physicians to access and understand their data.
Remember, appeals must be sent via e-mail, fax, or postal mail and must be received by UHC by January 27 to assure they will be reviewed prior to the publication of the physician ratings.