UnitedHealth Premium Program Frequently Asked Questions Resources u Phone: 866-270-5588 u Website: UHCprovider.com/Premium u Mail: UnitedHealthcare - UnitedHealth Premium Program MN017-W700 9700 Health Care Lane Minnetonka, MN 55343 Overview The UnitedHealth Premium program provides physician designations based on quality and cost efficiency criteria. This helps UnitedHealthcare members make more informed choices about their medical care. Physicians may also use these designations when referring their patients to other physicians. If an employer offers a tiered benefit plan, members may pay less when they use Premium Care Physicians. The program, which began in 2005, is the longest running physician quality and cost efficiency designation program in the industry. It received the National Committee for Quality Assurance (NCQA) Physician Quality (PQ) Certification and meets the Consumer Purchaser Disclosure Project s Patient Charter standards. The program consists of both quality and cost efficiency assessments, with quality serving as the primary measurement. This emphasis on quality demonstrates our commitment to evidence-based practice. Physicians who don t meet quality criteria are not eligible for the cost efficiency designation. The results of these quality and cost efficiency assessments are used together to determine the physician s designation. Designations are displayed on UnitedHealthcare s websites. Table of Contents Q1. How will I be notified of my designation?...2 Q2. Who s eligible for the Premium program?...2 Q3. What specialties are included in the Premium assessment?...2 Q4. What should I do if the incorrect specialty is shown in my assessment letter?...3 Q5. How are Premium designations displayed publically?...3 Q6. Will my designation change with each annual assessment?...3 Q7. Why did I receive a designation of Not Evaluated For Premium Care when my specialty is assessed in the Premium program?...4 Q8. Where can I view my assessment reports?...4 Q9. What Premium assessment reports are available?....4 Q10. Can I delegate access to my Premium assessment reports?...5 Q11. Are health care claims from nurse practitioners and physician assistants in my practice used in my assessment?...5 Q12. Why do you use health care claims data to measure quality and cost efficiency?...5 Q13. How can I learn more about the program methodology?..5 Q14. If my fee schedule is high, will this impact my cost efficiency results?...5 Q15. How does your methodology account for my non-compliant patients?...6 Q16. Is the methodology based on standards and statistical measurement?...6 Q17. Has your methodology been independently audited?...6 Q18. How can I request reconsideration of my designation result?...6
Introduction Q1. How will I be notified of my designation? A. In July 2017, you ll receive an assessment letter that includes your Premium designation and important program dates. The letter also includes instructions on how to access your assessment reports. Eligibility Q2. Who s eligible for the Premium program? A. The Premium program assesses more than 375,000 physicians across most states. Physicians are assessed by the Premium program when they meet all of the following criteria: Have an active UnitedHealthcare Commercial fee-for-service contract Practice in a state and county included in the Premium program Practice in a credentialed specialty included in the Premium program Multiple credentialed specialties may be combined into a single Premium specialty for the purposes of assessment. Q3. What specialties are included in the Premium assessment? A. The following is a list of the 16 specialties and 46 sub-specialties included in the program. Premium Specialties Allergy Allergy Allergy and Immunology Cardiology Cardiac Diagnostic Cardiology Cardiovascular Disease Clinical Cardiac Electrophysiology Interventional Cardiology Ear, Nose and Throat Laryngology Otolaryngology Otology Pediatric Otolaryngology Rhinology Surgery Head and Neck Endocrinology Endocrinology, Diabetes, and Metabolism Family Medicine Family Practice General Practice Preventive Medicine Gastroenterology Digestive Diseases Endoscopy Gastroenterology Hepatology Liver Disease General Surgery Colon and Rectal Surgery Proctology Surgery Surgery Abdominal Internal Medicine Internal Medicine Nephrology Nephrology Neurology Neurology Neurology and Psychiatry Neuromuscular Disease Neurosurgery, Orthopaedics and Spine Back and Spine Surgery Hand Surgery Knee Surgery Neurological Surgery Orthopedic Surgery Shoulder Surgery Sports Medicine Obstetrics and Gynecology Gynecology Obstetrics Obstetrics and Gynecology Pediatrics Adolescent Medicine Pediatrics Pediatric Adolescent Pulmonology Pulmonary Medicine Rheumatology Rheumatology Urology Urology 2
Q4. What should I do if the incorrect specialty is shown in my assessment letter? A. Your evaluated specialty is based on the primary specialty you reported to your contracted health plan. If your primary specialty is not correct, first determine if your practice uses delegated credentialing. If your practice uses delegated credentialing, please contact your internal practice credentialing administrator. If your practice does not use delegated credentialing, please contact your contracted health plan. After you complete the credentialing specialty change process, we ll update your primary specialty. If the change reflects a specialty that s included in the program, we ll assess your health plan claims data based on your updated primary specialty and send you an updated assessment result. Designation Results Q5. How are Premium designations displayed publically? A. Designations are displayed publicly in UnitedHealthcare s physician directories as follows: Premium Care Physician The physician meets the criteria for providing quality and cost-efficient care. Quality Care Physician The physician meets the criteria for providing quality care but does not meet the criteria or is not evaluated for costefficient care. Not Evaluated for Premium Care The program does not evaluate physicians in this specialty, there is not enough health plan claims data to evaluate, or evaluation is in process. Does Not Meet Premium Quality Criteria The physician does not meet the criteria for providing quality care so the physician is not eligible for the costefficient care designation Q6. Will my designation change with each annual assessment? A. Your designation may change with each assessment. The Premium program assesses physicians annually, using updated quality and cost efficiency methodologies and data. Physician designations are determined based on a comparison of current version and previous version assessment results. The current version assessment result is used when the physician s Premium specialty and/or geographic area changes from the previous version. The current version assessment result is also used when the physician s current assessment result is: Does Not Meet Premium Quality Criteria The same as or an improvement from the previous version The previous version assessment result is used when the physician s Premium specialty and geographic area are the same as the previous version and both of the following are true for the physician s current assessment result: Meets the quality criteria or does not have enough data for assessment Does not improve from the previous version You can see examples of these possible outcomes at UHCprovider.com/Premium 3
Q7. Why did I receive a of Not Evaluated For Premium Care when my specialty is assessed in the Premium program? A. The designation of Not Evaluated For Premium Care is used when one of the following applies: The UnitedHealth Premium program doesn t evaluate physicians in your specialty Your evaluation is in process You don t have enough health plan claims data to be evaluated for quality Since your specialty is included in the Premium program, your evaluation is either in process or you don t have enough health plan claims data to be evaluated for quality. Insufficient health plan claims data doesn t reflect the total number of members treated or the number of procedures performed by a physician. Rather, it reflects the statistical requirements of the Premium program, which include only health plan claims associated with specific program measures and relevant to the physician s designated specialty. In some cases, there may not be enough data to complete the analytic process from a statistical standpoint. Although you have patients who are UnitedHealthcare members, some may not have: The specific types of conditions that are measured in the program Health plan claims that are eligible for use in the program Complete episodes Episodes that meet measure-specific requirements You may also benefit from your medical group s assessment result. If you re an eligible physician but don t have a sufficient number of attributed measures for quality and/or a sufficient number of attributed episodes and/or patients for cost efficiency, you may meet the quality and/or cost efficiency criteria based on your affiliated medical group s assessment result for your Premium specialty. Medical group assessment is designed to benefit physicians within an affiliated medical group who share similar practice patterns and common care protocols. Reporting Q8. Where can I view my assessment reports? A. Your Premium assessment letter includes instructions on how to view your Premium assessment reports. Q9. What Premium assessment reports are available? A. The Premium program gives you access to a range of reports about your practice. You may use this information to support your efforts to provide quality and cost-efficient care to your patients. We want to ensure that you have comprehensive and transparent information about your assessment result. These reports provide information about how your designation was determined, including the conditions, procedures, measures and patient information used in your assessment. You can also determine how your results compare with those of your peers. The Assessment Summary report provides a high-level overview of your assessment result. The remaining reports show patient and service-level detail. These are separated into quality and cost efficiency. We also offer group-level reports for practice administrators. We suggest reviewing your assessment reports in the following order: Assessment Summary Quality Measure Detail Patient Total Cost: Service Category Patient Episode Cost: Service Category For more information about your designation result and assessment reports, please see the Report Guide included with your reports. 4
Q10. Can I delegate access to my Premium assessment reports? A. The Premium program s delegation of authority process allows you to give other UnitedHealthcareOnline.com users access to your Premium designation result, your Premium profile and preferences and your Premium assessment reports. You may want to delegate authority to members of your office staff so they can view your reports or help you submit an online reconsideration. When considering the delegation process, please remember that the reports include protected health information (PHI) as regulated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and applicable state law. Your delegates may only access, use or disclose this information as permitted by law. You may delegate the selected person with one of the following levels of access: Full Access allows a delegate to view your Premium results (which include patient information), make changes to your profile and request Premium reconsideration. Read-Only Access allows a delegate to view your Premium results (which include patient information), your profile and the status of your Premium reconsideration. Your delegates must be currently registered users of UnitedHealthcareOnline.com. If you wish to delegate authority to a non-active user, they ll need to register at UnitedHealthcareOnline.com. For more information about adding a delegate to view your reports, please go to UnitedHealthcareOnline.com > Quick Links > UnitedHealth Premium > Premium Profile & Preferences. Data Used for Assessment Q11. Are health care claims from nurse practitioners and physician assistants in my practice used in my assessment? A. When a nurse practitioner or physician assistant is the billing provider (using their own name and tax ID number), these claims can be included in your episodes just as claims from any other provider can be included. However, if claims from nurse practitioners and physician assistants are billed under your name and tax ID number, the claims for these services are considered the responsibility of the billing physician and could be used to attribute measures, patients and episodes to you for use in your assessment. Q12. Why do you use health care claims data to measure quality and cost efficiency? A. We rely primarily on health care claims data to assess quality and cost efficiency because paid claims data are commonly used by many types of organizations (e.g., health plans, academia, government agencies, public health agencies, health service research, specialty societies and others) to analyze and understand the aspects of health care delivery. In addition, the data is readily available, comprehensive and provides detailed information about the type, quantity and cost of services. The measures used in the Premium program have been designed specifically for use with health care claims data. Wherever possible, UnitedHealthcare first uses clinical quality measures from the National Quality Forum s (NQF) endorsed measures. Many of the claims-based NQF measures have been in use for decades. Methodology Q13. How can I learn more about the program methodology? A. To learn more about the Premium methodology, please go to UHCprovider.com/Premium. The UnitedHealth Premium Methodology document provides a summary of the methodology and links to specific topics such as attribution, statistical tests, and quality and cost efficiency assessment examples. It also has links to each Premium specialty s quality conditions, procedures and measures. Q14. If my fee schedule is high, will this impact my cost efficiency results? A. The cost efficiency assessment is based on total cost, a combination of resource utilization and unit cost. You could meet the criteria for cost efficiency even if your fee schedule is high if your claims demonstrate efficient use of medical resources (e.g., generic medications, shorter lengths of stay at the hospital, fewer redo procedures and complication-related expenses, appropriate use of diagnostic tests, etc.). 5
Q15. How does your methodology account for my non-compliant patients? A. Your actions, such as communication and patient follow-up, have a significant effect on whether or not your patients adhere to your recommendations. The methodology itself also mitigates the effects of your patients levels of compliance. Your performance is compared to the case-mix adjusted expected quality measure compliance count for each measure, rather than using an absolute threshold. The expected compliance count reflects a degree of non-compliance for each measure Measures that are primarily dependent on patient compliance, such as the rate of prescription refills, are not included in the assessment. Q16. Is the methodology based on standards and statistical measurement? A. The methodology builds upon industry standard techniques that have been continually reviewed through prior releases of the program. We draw on feedback from medical specialty societies, our own scientific advisory boards and physician advisory committees, as well as individual physicians. We also rely on advances in the medical literature and our own research to review the methodology. For more information, including calculations, please see the UnitedHealth Premium Methodology at UHCprovider.com/Premium. The underlying grouping software programs are commercially available and detailed descriptions of their operation are publicly available at optuminsight.com/transparency. The UnitedHealth Premium program applies statistical tests to determine if there is a statistically significant difference between the physician s performance and the benchmark. When there is a sufficient number of quality measures attributed, the chi-square goodness of fit test is applied to determine if the physician s performance is statistically higher than, statistically lower than or statistically not different from the benchmark. When there are a sufficient number of patients and/or episodes attributed, the Wilcoxon rank-sum test is applied to determine if the physician s performance is statistically lower than, statistically higher than or statistically not different from the benchmark. Q17. Has your methodology been independently audited? A. Since June 2008, the Premium program has met the stringent methodological requirements of the physician measurement elements of NCQA s Physician Quality Certification program. The NCQA Physician Quality Certification program evaluates how well health plans measure and report quality performance and cost effectiveness. The following principles guide NCQA s PHQ Certification program: Standardization and sound methodology Transparency Collaboration Designation Reconsideration Q18. How can I request reconsideration of my designation result? A. You may request reconsideration of your designation result by using our online reconsideration tool at UnitedHealthcareOnline.com >. The tool guides you through the process, indicating the items that can be reconsidered, and ensuring that you only submit the minimum information needed. You ll have time to review your results and request reconsideration, if needed, before your designation is displayed on our websites. The last day to submit reconsideration requests will be announced in the Network Bulletin and on UHCprovider.com. As long as we receive your request on or before this date, we ll process your reconsideration and update your result, if applicable. For more information, go to UHCprovider.com/Premium. 6
Important notes about the UnitedHealth Premium Physician Program The information from the UnitedHealth Premium program is not an endorsement of a particular physician or health care professional s suitability for the health care needs of any particular member. UnitedHealthcare does not practice medicine nor provide health care services. Physicians are solely responsible for medical judgments and treatments supplied. A Premium Care Physician or Quality Care Physician designation does not guarantee the quality of health care services members will receive from a physician and does not guarantee the outcome of any health care services members will receive. Likewise, the fact that a physician has a Not Evaluated for Premium Care or a Does Not Meet Premium Quality Criteria designation does not mean that the physician does not provide quality health care services. All physicians in the UnitedHealthcare network have met certain minimum credentialing requirements. Regardless of whether a physician has received a Premium Care Physician designation, members have access to all physicians in the UnitedHealthcare network, as further described under the member s benefit plan. The designation of Not Evaluated for Premium Care is given when a physician does not practice in a specialty that is evaluated by the Premium program, or when a physician s evaluation is in process. It is also given when a physician does not have enough health plan claims data to be evaluated, but it is not an indicator of the total number of patients treated by the physician or the number of procedures performed by the physician. Rather, it reflects the statistical requirements of the Premium program, which includes only health plan claims associated with specific Premium program measures and relevant to the physician s specialty. In some cases, there may not be enough data to complete the analytic process from a statistical standpoint. UnitedHealthcare informs members that designations are intended only as a guide when choosing a physician and should not be the sole factor in selecting a physician. As with all programs that evaluate performance based on analysis of a sample, there is a risk of error. There is a risk of error in the claims data used in the evaluation, the calculations used in the evaluation, and the way the Premium program determined that an individual physician was responsible for the treatment of the patient s condition. Physicians have the opportunity to review this data and submit a reconsideration request. UnitedHealthcare uses statistical testing to compare a physician s results to expected or normative results. There is a risk of error in statistical tests when applied to the data and a result based on statistical testing is not a guarantee of correct inference or classification. We inform members that it is important that they consider many factors and information when selecting a physician. We also inform our members that they may wish to discuss designations with a physician before choosing him or her, or confer with their current physician for advice on selecting other physicians. The information contained in this Frequently Asked Questions document is subject to change. Insurance coverage provided by or through UnitedHealthcare Insurance Company, All Savers Insurance Company, or their affiliates. Health plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California, UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Texas, LLC, UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc. or other affiliates. Administrative services provided by United HealthCare Services, Inc., OptumRx, OptumHealth Care Solutions, Inc. or its affiliates. Behavioral health products are provided by U.S. Behavioral Health Plan, California (USBHPC), United Behavioral Health (UBH) or its affiliates. D30074 1/18 PCA-1-006503-05192017_09062017 2018 United HealthCare Services, Inc.