How Your Payer Directory Profile May Harm Your Practice

March 15, 2017PayersContractsPatientsPearls


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Are you aware that insurance companies are ‘grading’ you? Do you know what your grade is? Do you understand how your profile can impact your patients, particularly if your score is not enough to make ‘top tier’? If you don’t, now is the time to pay attention to this issue.

GradingFrankly, payers grading physicians is nothing new. For at least the last decade or so large national payers have been keeping score. What is different now is that your score may impact which patients access you and ultimately, this may have an effect on your payment schedule soon too.  So while you may be aware that you are in, say, United Healthcare’s Premium Tier 1, where physicians are rated by quality and cost efficiency, or Aetna’s Aexcel Blue Star, which rates physicians based on patient volume, clinical performance, and efficiency (cost) for select specialties, do you understand what means to you?Primarily, these scores affect benefit design. Some employers design their benefits so that if a patient seeks services from, say, United Healthcare Premium Tier 1 physicians, they may have only a small copay to make or none at all. But if they access a physician outside of that tier, they may have a substantial copay or cost-sharing responsibility that they would not have if receiving care from a Tier 1 physician. This creates an access issue for you and your practice.Group vs. Individual

Further complicating the issue is the fact that most physicians are graded individually. That means that if you are Tier 1 but your partner is not, when you are out and your patient sees your partner, that patient is likely to subjected to that higher cost-sharing amount than when they see you. Obviously this creates a less-than-ideal experience for your patients. So what do you do about it?

Obtain Your Score

First, go to the payers’ online directories and look yourself up to see where you stand. In addition to seeing your grade, you will also see other information such as patient reviews and patient satisfaction scores and how your ‘costs’ compare to your peers in the same specialty and region. We are in the era of ‘big data’ now and payers are taking full advantage of pulling together various pieces of information to present a content-rich profile of providers in their networks. Sources of patient review data come from such companies as HealthGrades and

If you have not scored well, you will want to find out the reasons contributing to your lower overall score. Contact the plan and ask them to send you the data upon which you have been rated. Annually, the payers typically mail out this information to you and you typically have 30 days to respond to any inaccurate data. MAKE SURE YOU REVIEW THESE PACKETS! In 100 percent of the cases where our clients have asked us to perform a review of that data, we have found errors — patients that should not be attributed to that physician, services that are not provided under that specialty, and so on. Therefore, look over the data carefully and compare it to your own records.

Factors Contributing to Low Scores

Once you receive the data you will want to have a complete understanding of the metrics used to arrive at your score. Higher costs are often not just a function of the care that you provide directly, but may be a result of referring to a highly paid specialist or admitting patients to the most expensive hospital in the region. Therefore, improving your score may require a change in to whom you refer and where you refer. Note that once your grade is issued, if the payer does not receive any indication from you that that data is erroneous, that will be your score for the year and will not be modified until the next grading period. We have seen clients lose dozens of patients in these cases, so don’t let this happen to you too!

Be Proactive

To maintain or improve your score, take proactive steps to ensure that your next grade will be good. Identify the specialists to whom you refer and look them up in the payers’ directories too. Are some noted as high cost? Then you may want to refer to another who is within the average cost range and who is rated in the top tier. Also look up the hospitals with which you are associated — if they are not in the top tier, you may need to consider whether or not your score is going to be affected by the cases you refer there.

Be Visible

Patients are utilizing online directories more than ever before as their benefits become directly tied to the quality tiers from which they access care. When patients are searching for a provider by area or specialty, if you are not highly rated, you may not even show up in the offered list of providers resulting from that search. For example, in United Healthcare’s directory, searching for a specialty or facility within a region automatically defaults to a list of Premium Tier 1 providers and Tier 1 hospitals. So in order to remain visible, you must improve your score in order to be found.

While this does not seem like good news for physicians, the upside is that you can change your score and improve your position so that patients can continue to have access to you. But it requires that you do your research and that you carefully review any mailed data that comes your way from a payer and that you take the steps necessary to protect your profile.