Keep Insurers Honest

TMA: Appeal Your Health Plan Rankings 

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Medical Economics Feature – August 2012 

Tex Med. 2012;108(8):41-44.

 By Ken Ortolon 

In spring 2011, Aetna notified El Paso plastic surgeon Deborah Seelig, MD, it was dropping her from its Aexcel physician network for not meeting certain criteria under the network's physician-ranking program.

But when she reviewed the data Aetna used, she found it seriously flawed.

"It turned out the numbers gave away the entire story," Dr. Seelig said.

In one instance, Aetna dinged Dr. Seelig for an adverse outpatient event that occurred before she ever started treating the patient.

In another, it held her responsible for the cost of an entire episode of care for a patient who had complications from surgery performed by another physician in another city. Aetna assigned $11,300 in treatment costs for that patient to Dr. Seelig even though it had paid her only $650 for the care she actually provided.

"I thought that was grossly unfair," she said.

Dr. Seelig decided to appeal her Aexcel ranking under a state law the Texas Medical Association worked hard to pass in 2009. And, using a step-by-step appeals "toolkit" that TMA developed, she succeeded in overturning Aetna's decision and winning reinstatement into the Aexcel network.

TMA officials say Dr. Seelig may be among only a handful of physicians who have used the new law to challenge health plan ranking programs because most of the major plans had suspended their ranking programs after the legislature passed the law.

But some of those insurance companies are preparing to roll out updated versions of their ranking programs early next year. TMA officials say physicians need to be aware of their rights and how to appeal any adverse rankings under the new law.

Gaining Due Process 

On its website, Aetna says Aexcel helps patients find the right doctor. "Aetna's physician performance network makes the search easier," the website says. "Members get access to specialists who have met certain industry-accepted practices for clinical performance and Aetna measures of cost-efficiency."

The company adds that the network helps members make informed health care decisions, lower their medical costs, and get access to quality care. 

But TMA felt Aexcel and other health plan ranking programs weren't all the insurance companies advertised them to be. TMA pushed legislators to give physicians due process rights and make sure programs based more on cost than on quality of care do not mislead patients.

The law limits health plan physician ranking or tiering based on performance on both cost and quality measures and gives physicians new rights to appeal those rankings.

The law, sponsored by state Rep. John Davis (R-Houston) and Sen. Robert Duncan (R-Lubbock), requires ranking programs to use nationally recognized standards and guidelines and requires insurance plans to disclose those measurements to physicians before the evaluation period. It also gives physicians the right to dispute their rankings before insurers publish or advertise them to the public.

The National Quality Forum or the AQA must endorse the standard, measure, or guideline the health plans use. If neither group has a standard, measure, or guideline for an issue, then the plans must follow those the National Committee for Quality Assurance endorses.

Plans that violate the law are subject to sanctions and disciplinary action by the Texas Department of Insurance (TDI).

The law does not cover Medicaid or Medicaid managed care plans, the Children's Health Insurance Program, Medicare Advantage plans, or Medicare supplemental benefit plans.

TMA staunchly backed the law because physicians lacked due process in the way health plans implemented their ranking programs before 2009.

During a Senate State Affairs Committee hearing in May 2009, then-Austin physical medicine and rehabilitation specialist Charlotte Smith, MD, said health plans were not disclosing the measurement and performance standards to physicians before the evaluation period; thus physicians could not modify their practice to meet the new standards. She also said the rankings, "which often are imprecise or incorrect," were made public on websites or elsewhere without giving physicians a chance to dispute them.

"Physicians' professional reputations can suffer harm when incorrect ratings, rankings, tiering, or comparisons are made public prior to the ability of the physician to challenge the ranking," Dr. Smith told the committee. "Patients also are misled because the rankings are portrayed as a 'quality' ranking, when in actuality the ranking is a cost-efficiency ranking that is beneficial to the health plan."

Dr. Smith said it is critical that plans provide physicians due process and a fair hearing before publishing any rankings.

Rolling Out the Rankings 

Genevieve Davis, director of TMA's Payment Advocacy Department, says physicians' use of their appeal rights has been low so far because most of the major health plans suspended their programs while they prepared to adapt to the new law. Aetna was one of the first to reinstate its ranking program. Aetna informed physicians in late 2010 it would update and publish the Aexcel rankings in 2011. So Dr. Seelig may be one of only a few physicians who have successfully appealed their rankings.

But Ms. Davis says physicians need to be ready to appeal their rankings because more health plans are on the verge of reinstating their programs.

"CIGNA and UnitedHealthcare are preparing to roll out updated ranking and tiering programs that will take effect in early 2013. This is an opportunity for physicians to review their data and utilize the TMA toolkit if they want to appeal an adverse ranking with the health plan."

The TMA toolkit includes information about physician rankings, which health plans have ranking or tiering programs, and step-by-step instructions on how to appeal rankings.

Among those steps are collecting and reviewing all letters and documentation received from the health plans and determining if the plan in question is subject to the provisions of the law.

Next, determine the basis for your appeal, such as inaccurate data or the health plan's failure to disclose its standards and measures before the evaluation period. Then, begin the appeal by requesting data pertinent to the ranking and asking for a review within 30 days of receiving notice of the ranking.

TMA officials suggest physicians educate their staff to watch for letters from health plans regarding rankings to ensure that they can meet appeal deadlines and have adequate time to review the data.

The final step is to file a complaint with TDI if you believe the health plan has not adhered to the requirements of the law.

Dr. Seelig says TMA and its toolkit were "incredibly helpful when it came down to getting the confidence to try to appeal these rankings." She says reviewing Aetna's ranking data and pulling the information to refute it was time consuming, but appealing a health plan's ranking could be well worth your time if patients from that plan are a significant part of your practice.

"If it's a small payer and it's not going to make a big difference in the type of patients who are continuing to follow through with the practice, it may not make such a big difference. However, if it is a major payer, then it really behooves the individual to take some time and make an appeal so it doesn't create downstream payment issues because you're seeing fewer patients from that payer," she said.

While Dr. Seelig said Aetna is not a major part of her practice, she felt appealing was the right thing to do. "If you don't say anything when it's not right, then it's going to continue to happen."


TMA Toolkit Helps You Challenge Adverse Health Plan Rankings 

TMA has developed a toolkit to help physicians challenge poor ratings from a health insurance plan ranking program.

"Basic Steps for Reviewing and Disputing Physician Rankings and Tierings in Texas under Chapter 1460, Insurance Code," includes step-by-step instructions on how to gather information to refute health plan rankings and how to initiate an appeal of those rankings.

TMA developed the toolkit to help physicians take advantage of provisions of House Bill 1888, which passed the Texas Legislature in 2009 and gives physicians the right to appeal health plan rankings before insurers publish them.

To get the instructions and other information about your rights under physician-ranking programs, go to TMA's website.

August 2012 Texas Medicine Contents
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