UnitedHealth Premium SM

Transcription

1 Physician s Commonly Asked Questions June 17, 2005 UnitedHealth Premium SM Designation Program 1. What is the UnitedHealth Premium designation program? The UnitedHealth Premium designation programs recognizes specialty and primary care physicians and cardiac facilities that meet or exceed certain evidence and consensus based quality standards and efficiency standards. The program is an information tool for UnitedHealthcare enrollees to use that helps them to make informed decisions about their health care. This program is an extension of our long standing commitment to supporting evidence-based medicine and the use of data to identify opportunities for improvement such as physician data sharing (PDS) and the distribution of Clinical Evidence. 2. Why does the program exist? UnitedHealthcare believes that health care in America can and must work better. Variation in care delivery is a recognized issue. Clinical societies and consumer quality coalitions are addressing this issue by developing evidence-based medical guidelines. UnitedHealthcare has taken this idea one step further to create the UnitedHealth Premium designation program. This innovative program is designed to support adherence to evidence based practice standards along the continuum of care, promoting affordability and quality for our customers and their employees. Using evidence-based medical guidelines, nationally accepted clinical standards and expert independent physician advice, we use evaluate UnitedHealthcare claims data and survey answers to evaluate network physicians and hospitals against critical sets of quality and efficiency criteria. 3. How will I know if I am designated? All physicians who practice in one of the eligible medical specialties will receive communication advising of their designation status. 4. Do I have to be board certified to be designated? Yes, board certification or board eligible is one of the requirements in order to receive the designation. 5. What are the benefits of the UnitedHealth Premium designation program? UnitedHealthcare promotes physicians and facilities who meet either the quality only or quality and efficiency criteria to customers and to their employees. As a result, there is potential that designated physicians will see an increase in the volume of patients accessing their practice. Physicians also have access to evidence based information and peer-to-peer comparison data shared by UnitedHealthcare as part of this designation program. Eligible designated physicians performing at the highest levels may also participate in Practice Rewards, a limited pilot program in 2005 that provides physicians with enhanced reimbursement as part of the designation program. 6. What if I am part of a group practice and only part of the group receives the designation? Currently, designation is only available at the individual physician level. However, in the fall of 2005, group designation will become available for eligible groups and the details will be shared at that time. Copyright 2005 United HealthCare Services, Inc. All Rights Reserved.

2 7. What is the designation methodology? Briefly, the designation criteria are based on nationally recognized and established evidence and consensusbased performance measurements. In August, 2005, look for the detailed specifics regarding the methodology at the physician web site online at 8. Who can I talk to at UnitedHealthcare about the UnitedHealth Premium designation program? UnitedHealthcare has made information regarding this program readily available to physicians and facilities. Detailed information can be found at the physician web site, on the consumer web site of myuhc.com as well as the communications sent by UnitedHealthcare providing physicians with additional contact information. Physicians and facilities may also contact the toll-free number of prior to July 15 th. After July 15, 2005, physicians and facilities can contact Can I appeal my non-designated status with UnitedHealthcare? Yes, you can ask for reconsideration of your designated status. While we will review your designation status and the underlying information specific to your situation, we will not alter the program s methodology. Requests for reconsideration will be considered when a physician can demonstrate that UnitedHealthcare claims data does not accurately represent care provided to the enrollee or if the physician can demonstrate claims data inconsistency that impacts the designation analysis. Physicians may initiate this reconsideration process through written request sent to UnitedHealthcare Physician Recognition Programs Mail Stop MN012-S117, 5901 Lincoln Drive, Edina, MN or by sending an to unitedpremium@uhc.com. 10. How often will designation take place, and when is the next designation? The UnitedHealth Premium designation is an annual process and occurs during the summer of each calendar year. Cardiac facilities must apply for the designations and are re-designated annually. Oncologists must apply for the designation and are not required to complete an annual questionnaire. All other eligible specialties do not require an application. 11. How can the designation program really measure my quality of practice? Quality is evaluated based on disease and specialty specific criteria. The quality benchmarks are based on scientifically valid standards, tied to clinical processes and evidence and consensus based rules that meet national guidelines. The UnitedHealth Premium quality designations incorporate the recognition of primary care physicians under the NCQA diabetes and heart/stroke physician recognition programs and the recently released Ambulatory care Quality Alliance (AQA) consensus measurements. Physicians who meet the quality benchmarks receive the UnitedHealth Premium quality designation. 12. What does the confidence interval mean? For specialties using claims analysis methodology, we evaluate claims data for your practice using UnitedHealthcare enrollee claims. Using your actual data, statistical confidence intervals are constructed based on your sample size to determine, with 95% confidence, the probable range of your quality and/or efficiency scores. These intervals are then applied against your local geographic area threshold. Due to the level of confidence intervals used, we are 95% confident that the designated physicians who meet or exceed the quality or efficiency measurements are better than the local geographic area thresholds. 13. Why isn t quality the primary measurement over efficiency? Quality is considered the primary measurement, demonstrating our commitment to evidence-based practice. The quality designation is separated from the efficiency designation. Physicians must first meet the quality benchmarks in order to proceed to the efficiency analysis. Physicians who meet the quality benchmarks will receive the quality designation regardless of their efficiency analysis. June 17, 2005 Page 2 of 7

3 14. I am in a specialty excluded from the UnitedHealth Premium Designation program; why is that? At this time, some medical specialties do not have established evidence-based guidelines for quality performance measures available for use in the program. Specialties for which there are no quality criteria are not evaluated for either quality or efficiency. The specialties that are currently excluded are: Colon Rectal Surgery Dermatology Gastroenterology General Surgery Hematology Neonatology Nuclear Medicine OB/Gyn Ophthalmology Otolaryngology Pediatrics Plastic Surgery Rehabilitation Medicine Therapeutic Radiology Urology Vascular Surgery 15. When will criteria be available for the excluded specialties? For many of the listed excluded specialties, we are working to incorporate evidence-based guidelines. In 2006, many of these specialties will have evidence-based guidelines available, and at that time will be eligible for participation in the designation program. Other specialties are continuing to develop evidence-based criteria that should be available in the next year or two. 16. Isn t this a way to tier your network for economic reasons? No, it is in response to our clients and enrollees request for information. The designations are one tool to assist consumers in making informed decisions about their healthcare. It is important to note that UnitedHealth Premium is not a separate network or a network within a network. All UnitedHealthcare enrollees have access to the broad national UnitedHealthcare network of physician and hospital participants regardless of their designation status. Physicians must meet the quality benchmarks in order to proceed to the efficiency analysis. Physicians who meet the quality benchmarks will receive the quality designation regardless of their efficiency analysis. 17. Why is the NCQA recognition program incorporated into the UnitedHealth Premium program? UnitedHealthcare is the first health care company licensee of Bridges to Excellence (BTE). BTE is an employer sponsored pay-for-performance program that utilizes NCQA physician recognition programs to drive advances in the quality of care and reduce waste and inefficiencies through accountability and financial incentives. Primary Care physicians and endocrinologists with recognition through the NCQA Diabetes Recognition program will meet the UnitedHealth Premium quality criteria. Primary Care physicians with recognition through the NCQA Heart/Stroke program will meet the UnitedHealth Premium quality criteria. This provides physicians with an alternate way to receive the UnitedHealth Premium designation. June 17, 2005 Page 3 of 7

4 18. How can consumers determine who is designated through the UnitedHealth Premium program? UnitedHealthcare identifies designated physicians and cardiac facilities in both online and print provider directories. UnitedHealth Premium designations will be identified as the following: Quality Only Quality and Efficiency Not Rated 19. Am I expected to refer patients to designated physicians, if available? We believe the UnitedHealth Premium designations can help inform both consumers and physicians. We would encourage you to consider the information in your referral decisions. Some of your patients may have health plan benefit designs that provide incentives for them to receive care from designated physicians. Your participation agreement, however, requires you to refer to and/or utilize network physicians and facilities. 20. What if I don t have enough UnitedHealthcare claims to be designated? The adoption of the confidence interval methodology allows us the opportunity to consider physicians for designation who have a lower volume of UnitedHealthcare claims. Primary Care physicians and endocrinologists with recognition through the NCQA Diabetes Recognition program will meet the UnitedHealth Premium quality criteria. Primary Care physicians with recognition through the NCQA Heart/Stroke program will be deemed to have met the UnitedHealth Premium quality criteria. This provides Primary Care physicians and endocrinologists with a low volume of UnitedHealthcare claims an alternate way to receive the UnitedHealth Premium designation. The future introduction of group designation is another method to aggregate data among your partners to increase the volume of UnitedHealthcare claims data. 21. Can I be designated by other methods than claims analysis? Yes. Primary Care physicians and endocrinologists with recognition through the NCQA Diabetes Recognition program will meet the UnitedHealth Premium quality criteria. Primary Care physicians with recognition through the NCQA Heart/Stroke program will meet the UnitedHealth Premium quality criteria. 22. What if my fee schedule is high, causing me not to meet the efficiency criteria? The efficiency analysis is based on total cost, a combination of resource utilization and on unit cost. Even if your fee schedule was high, if your UnitedHealthcare claims demonstrate efficient use of medical resources, a lack of re-do procedures and lack of complication-related expenses, you could receive the efficiency designation. 23. Will you designate Nurse Practitioners and Physician Assistants in the UnitedHealth Premium program? No, the designation program is for medical doctors and doctors of osteopathy who possess an unrestricted medical license. June 17, 2005 Page 4 of 7

5 24. Can having a Nurse Practitioner or Physician Assistant in my practice play a part in my designation? Yes, if they are billing under your medical tax identification number (TIN), they are included in your UnitedHealthcare claims analysis for quality and efficiency. 25. If I do not become designated in 2 or 3 years, could I be terminated from the UnitedHealthcare network? Not as a result of the lack of designation. As long as you remain a credentialed UnitedHealthcare network participant, you can continue to see UnitedHealthcare enrollees regardless of your designated status. 26. If I am not designated, will this affect my future fee schedule? All UnitedHealthcare network participants are paid per the terms of their current contract regardless of the designations status. However, designated physicians practicing at the highest levels may be eligible to participate in Practice Rewards, where available, which does offer a higher reimbursement. 27. Will I receive a financial reward if I receive the UnitedHealth Premium designation? Designated physicians combined with appropriate use of clinical and administrative resources may be eligible for rewards through fee schedule enhancements offered by Practice Rewards, where available. 28. Will not being a designated physician effect my relationship with CMS or any other managed care organization? No, our designation program should not affect your relationship with CMS or any other managed care organization. 29. Will hospitals have access to my designation status? All physicians who receive the UnitedHealth Premium designation will be identified in online and printed physician directories. UnitedHealthcare s communication around designation is focused on consumers and physicians. 30. Could my designation status affect my hospital privileges? No, the program was developed in response to our customers desire to apply an objective quality and affordability assessment to our network while preserving choice and access for their enrollees. 31. What is the date range used for the claims analysis? Claims submitted to UnitedHealthcare for calendar year 2003 and paid through 2004 are used in the UnitedHealth Premium designation evaluation. 32. I am an orthopedic physician and I previously completed a survey to participate in this program. Will I have to complete a survey every year to maintain my designation status? Completing a survey upfront is no longer a participation criterion in order to be designated as a UnitedHealth Premium orthopedic physician. Musculoskeletal physicians who are designated will have an option to voluntarily complete a survey which will be used to identify individual information such as sub-specialty focus (e.g., foot/ankle). Physicians who complete the survey will have their subspecialty focus identified on the consumer website. Physicians who do not complete the survey will be identified to consumers as general orthopedic. 33. Are claims taken into consideration when evaluating oncology physicians for designation? No, claims are not evaluated at this time for oncology designation. Claims do not include information regarding stage of disease, whether the disease is localized or metastasized or if the disease is a new diagnosis or a reoccurrence. Therefore, oncology and hematology physicians who provide adult oncology June 17, 2005 Page 5 of 7

6 services and complete the survey will only be designated for quality until such time that quality and/or efficiency claims criteria can be determined. 34. I am an oncologist who practices at a center that is contracted with Cancer Resource Services. Is this the same as being designated for UnitedHealth Premium? UnitedHealthcare has two oncology programs. The is a designation program for physicians that meet quality criteria. Cancer Resource Services is a network of cancer programs that focuses on the treatment of uncommon and complex cancers. These two programs complement each other. Physicians need to complete the questionnaire to be eligible for designation with the UnitedHealth Premium program regardless of their participation status with a Cancer Resource Services facility. 35. I received a packet of information inviting me to complete an oncology survey for participation. Do I need to complete this survey? All UnitedHealthcare network oncology and hematology participants were mailed an oncology packet. The packet did include a questionnaire that needs to be completed and returned to UnitedHealthcare in order to be considered for designation with the. Physicians who complete the questionnaire will receive written communication regarding their designation status with UnitedHealth Premium. 36. I didn t receive an oncology packet and would like to complete the questionnaire for possible participation. Who do I contact to request a packet? Physicians may contact customer service at to request an oncology packet. 37. My facility is already designated as a UnitedHealth Premium cardiac care facility. How long is the designation valid? All currently designated UnitedHealth Premium cardiac facilities as well as prospective facilities received a letter requesting that they complete an online RFI for consideration as a designated facility for the new designation year of July 1, 2005 June 30, All RFIs will be reviewed in June with communication in July notifying the hospitals of their designated status. Facilities that are currently designated but fail to complete the RFI will lose their designated status as of June 30, Designations will not be available until Will the patient ID card identify the co-pay to collect from the patient based on the designation status of the physician? UnitedHealthcare enrollee ID cards may not identify co-payment amounts. Any questions regarding the UnitedHealthcare enrollee benefits or financial responsibilities can be directed to the toll-free physician number of or by verifying patient benefits and eligibility by using the physician website of How are procedures, lab work, hospital-based services impacted by the designation? These types of services are not designated. However, since the program uses Episodes of Care to evaluate quality and efficiency, the timing, frequency or cost of these services may have an impact on the quality and/or efficiency designation of a physician. 40. Will the UnitedHealthcare directories reflect the NCQA designation programs for Diabetes or Heart/Stroke? The online directory, myuhc.com, viewed by UnitedHealthcare enrollees will identify the NCQA designations in addition to the UnitedHealth Premium designations. The paper directories will reflect the NCQA designations in the Fall/Winter 2005 release. June 17, 2005 Page 6 of 7

7 41. What is the status of the UnitedHealth Performance program? The UnitedHealth Performance program was a pilot program introduced on behalf of three customers in 13 states that designated physicians who provided medical services for common, chronic conditions. Based on the pilot experience, feedback from physicians, medical and specialty societies, new data sources and national developments in physician quality and efficiency standards, the UnitedHealth Performance program pilot is being closed and no new employer groups will be added. As of July, 2005, the UnitedHealth Premium will be enhanced to encompass the common, chronic conditions along with the more complex conditions of cardiology, musculoskeletal and oncology. The three pilot customers will continue to access the UnitedHealth Performance program. Going forward, only the enhanced UnitedHealth Premium designation program will be available to customers and their employees. 42. I am a physician designated for UnitedHealth Performance. Will I remain designated under this program? Yes, designated physicians will remain designated until the third quarter of At that time, all physicians will be re-evaluated for designation under the UnitedHealth Premium designation program. 43. Where do I call if I have questions regarding my designation status? Physicians can call toll-free to prior to July 15. As of July 15, 2005, physicians can contact the physician self-service toll-free number at Who comprise the Scientific Advisory Boards? The role of Scientific Advisory Board is to provide professional and clinical expertise to UnitedHealthcare. The Board is comprised of independent physicians from academic centers such as the Harvard School of Medicine and The Cleveland Clinic as well as community affiliations. Board members are chosen based on their demonstrated contributions to the medical fields, including local and national leadership experience, clinical expertise, professional or academic appointments and individual accomplishments including research, publications and national awards. June 17, 2005 Page 7 of 7