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Learn How to Challenge Flawed Ratings, Tiers

The Doctor's Office, December 3, 2009

Payers have various rating, tiering, and ranking systems that attempt to assess a physician's performance against his or her peers. Some of these systems may be tied to reimbursement rates, but mostly they are used to steer patients to physicians in the higher-quality tier.

Often, say critics, the criteria on which the ratings are based are not disclosed to physicians in advance—when they could make changes to their practice. Moreover, many providers and consultants say the ratings are often incorrect, or at least imprecise. They also say the ratings may have more to do with cost than quality.

These rankings are an increasingly important part of marketing for health plans, so it's unlikely you will be able to opt out of them, says Jeffrey B. Milburn, Colorado Springs–based independent consultant at MGMA Health Care Con-sulting Group. But you can probably include provisions in your contract to help ensure accuracy. Milburn says such provisions should include:

  • The opportunity to review how the program operates. Ninety days would be ideal, but usually you can get 30–60 days notice, Milburn says.
  • Knowledge of the data being used. You want to be able to confirm that quality rankings are based on quality measures and not cost (efficiency) measures.
  • Knowledge of where data come from. You want something more detailed than someone saying, "It comes from claims."
  • Knowledge of the plan's methodology. How is the plan using the data?
  • Knowledge of the specific standards. Is the plan using a legitimate third-party organization?
  • Consideration of acuity. Too often, acuity isn't considered, Milburn says. You don't want the plan merely to acknowledge this; you want to see how it's factored in. Otherwise, you may be placed in a different tier because you have more severely ill patients.
  • An opportunity to appeal before the rankings are published. If you have concerns, you want them addressed before the rankings are made public.

If you think the data are incorrect, ask for a meeting. "I haven't had anyone turn me down. If the representative is reluctant to meet, appeal to the plan's medical director," says Milburn. If the plan is unwilling to give you that access, you may have a problem.


This article was adapted from one that originally appeared in the December 2009 issue of The Doctor's Office, a HealthLeaders Media publication.

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