Challenging your rating: You don't have to accept what the health plan says

There are steps you can take to change the assigned ranking.

By Emily Berry — Posted March 23, 2009

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Like many doctors practicing in Massachusetts, Cambridge pediatrician Michael Yogman, MD, MPH, had an early and unhappy experience with physician ratings.

Beginning in July 2006, after a mandate from the state's Group Insurance Commission, which handles benefits for public employees, physicians who contracted with Tufts, Unicare or Harvard Pilgrim were ranked for quality and cost. The rankings meant more than a gold star or lack of one in a physician directory -- they meant a higher co-pay for patients to see doctors who were not in the highest tier.

When one of the three plans didn't rate him in the highest tier, Dr. Yogman said he first got mad. Then he got busy with an appeal.

"I took it as a personal assault on my integrity," he said. "I was not about to stand for being considered a less-than-optimal physician on anybody's ranking."

Many physicians either upset with health plan rankings in general, or particularly upset at, what they feel is an unfairly low ranking share Dr. Yogman's feelings.

"The biggest fear physicians have is the fear of public discredit," said Bruce Bagley, MD, medical director for quality improvement at the American Academy of Family Physicians.

The largest health plans have promised to grade fairly, and organized medicine is working to ensure they stick to those promises. Practice management experts and organized medicine are already helping some doctors challenge assessments, and say there are good reasons to take the time to do it.

Some of the large national plans are in the midst of launching or relaunching their quality designation and grading programs this spring, and have either sent or will soon be sending notifications to physicians regarding opportunities to appeal their rating.

Major plans doing business in New York, including Cigna, Aetna, WellPoint and UnitedHealthcare all reached agreements with the state attorney general's office in late 2007 to base their physician ratings on more than cost, and to make the basis of their ratings transparent. As part of those agreements, the plans agreed that physicians would have the opportunity to appeal their ratings or designations. Aetna and Cigna also pledged to use the same guidelines across the country.

A few months later, Aetna, Cigna, WellPoint and United signed the Patient Charter for Physician Performance Measurement, Reporting and Tiering Programs, an agreement which sets clear expectations that physicians would have a fair chance to appeal any designations or rankings.

When plans haven't appeared to follow their pledges for transparency and fairness, experts said the first step to consider is whether it's worth your time to appeal. In some cases, it won't be -- particularly if co-pays aren't affected, and your designation is listed only online, Dr. Bagley said.

Then there's the time factor.

The daunting time commitment that comes with appealing a rating or designation does drive some doctors to decide it's not worth the trouble, said Marilyn Rissmiller, director of the Division of Health Care Financing at the Colorado Medical Society. A state law that took effect in September 2008 gives Colorado physicians the right to appeal quality and cost ratings and to examine the records associated with any scores or designations. It can take "hours and hours if you really want to get into it," she said.

A physician who feels strongly enough to take the time to make a challenge should first ask for the records associated with his or her rating, experts said.

Those are sometimes encrypted, so you should ask for the "drill-down" data that does identify individual patients, said Elaine Kirshenbaum, vice president for health policy at the Massachusetts Medical Society.

Rissmiller said once you have those records in hand, it may save time to find out whether improving a particular measure would change your designation. Focus on checking the accuracy of the data used to determine your score. If you were penalized for patients who aren't yours, or if there is a legitimate reason for an outlier, bringing attention to that may be enough to change your rating, she said.

"Even though the physicians may want to clear the record, if they're going into it under a time crunch, they need to just zero in on the area that's going to make the difference," she said.

If you have information that would change your score, the next step is to ask for a meeting, either in person or by phone, with someone who can discuss your rating and has the authority to change it. Make your requests for reconsideration and send your own records by certified mail so the plan can't claim it never received them, Kirshenbaum said.

Regardless of whether you're unhappy or satisifed with your rating, the AMA recommends educating your patients about physician profiling.

Dr. Bagley said doctors should tell patients when they challenge a ranking. "If I were in that situation ... I'd say, 'We're looking into why we didn't receive the designation. We're going to try to find out if we have a problem and fix it.'"

Experts also advise speaking to your local and state medical society.

The Massachusetts Medical Society has sued the Group Insurance Commission over what its members say is a faulty rating system. The GIC is defending its system.

Dr. Yogman followed all the right steps. His training in statistical analysis prepared him to do a thorough audit of the data the plan used to rate him. He spent hours comparing the claims data with his records. He found logical errors. For example, it appeared he had been graded by one measure meant for obstetricians. He was considered expensive when it came to well-child care, but he said those payments were in a fixed amount.

These types of errors, the AMA and other groups have found, are the most common reasons for faulty ratings.

But when Dr. Yogman reported those problems to the health plan that had put him below the top tier, he said he got nowhere. The GIC did not return calls seeking comment on Dr. Yogman's case.

But experts say sometimes a seemingly unsuccessful fight to change ratings for a certain year might bear fruit in subsequent years, once the rating organization sees your evidence. A year after his appeal, Dr. Yogman was reassessed, and this time, without explanation, he was placed in the top tier.

Dr. Yogman says he still has the reams of paper records he got from the health plan, filed away in a cabinet at home.

"The sad thing for physicians is that we spend time reviewing this kind of stuff," he said. "I would much prefer to be either reading journal articles or reading fiction than poring over bad data."

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Bad rating? What's the next step?

Though health plans aren't always consistent in how they rank or grade physicians, experts who have helped doctors appeal their designations have some standard advice they give their clients:


  • Spend your time attacking the idea of ratings or the plan in general. You'll have better luck the more specific you can be about what you're challenging.
  • Expect ratings to go away.


  • Review your contract and check whether the health plan has the right to rate your performance.
  • Ask for a copy of your rating and the records used to determine your designation. Specify that you need "drill-down" information, identified by patient and not encrypted.
  • Look for common mistakes, such as patients incorrectly assigned to you or unusual cases that weren't caught in the course of the program's risk adjustment.
  • Have your own records in order to directly challenge a problem with your rating.
  • Send all written communications by certified mail.
  • Ask for a meeting by phone or in person with someone who can go over your assessment with you.
  • Make sure the plan understands how the problems are affecting your patients -- their members. Are their members complaining? Switching doctors? Switching insurance companies?
  • Be open to improving based on what you learn.
  • Know your rating may not be changed in response to your challenge.
  • Keep in touch with your medical society -- it may be able to help you get answers from health plans, and it needs to know about your case to look for patterns in the problems with plan designations and rankings.

Sources: AMA Practice Management Center; Bruce Bagley, MD, medical director for quality improvement, American Academy of Family Physicians; Ellen Kirshenbaum, vice president for health policy, Massachusetts Medical Society; Marilyn Rissmiller, director, Division of Health Financing, Colorado Medical Society

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What to tell patients about your rating

The AMA and the Colorado Medical Society have prepared a poster for physicians' offices meant to educate patients about unfair physician profiling. The wording is below:

To our patients

It is our privilege to provide medical care to you and your family. Providing quality care to each of you based on your individual needs and desires is a responsibility we take very seriously.

You may have heard about recent efforts by insurance companies to "rate" physicians, supposedly based on the quality of care the physician provides. These systems often rate quality based on cost using computer programs that look at numbers and dollar amounts.

This is not the best way to judge whether or not you receive "quality" care -- no cost-based computer program in the world can do that.

As a patient, you need confidence that your physician will provide you with the best medical care and not simply the cheapest. The easiest way to provide cheap health care is to provide less health care--and that is not fair to you.

We support scientific efforts designed to improve health care quality, and the American Medical Association has established appropriate guidelines to measure physician quality. Unfortunately, most current insurance company rating systems do not meet these guidelines.

Please let us know if you have any questions about the medical care you receive in our office.

Our No. 1 goal is to provide you with quality medical care.

Poster #NC424607 is free to AMA members; 800-621-8335.

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Ribbons and stars

Some of the largest health plans are launching, expanding or relaunching their physician quality and cost designation programs this year. Among the plans and their designations:

Program Recognition
UnitedHealthcare Premium Designation Program 1 to 3 stars
WellPoint Blue Precision Check marks
Aetna Aexcel Blue star
Cigna Care Network Partial Cigna logo

Note: Blues plans not owned by WellPoint also have implemented physician quality programs under the "Blue Precision" name.

Source: Health plan Web sites

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External links

"Aetna's 'Aexcel' Program Measured Against AMA's Principles for Pay for Performance Programs," AMA Practice Management Center (link)

"Understanding Aexcel," from Aetna (link)

"Cigna Care Network Measured Against AMA Principles for Pay for Performance Programs," AMA Practice Management Center (link)

Cigna Care Network (link)

"UnitedHealthcare's Premium Designation Program Measured Against AMA Principles for Pay for Performance Programs," AMA Practice Management Center (link)

UnitedHealth Premium program (link)

"Tiered and narrow physician networks: How to challenge your profile or placement," AMA Practice Management Center (link)

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