What to Do If an Insurer Profiles You as a High Utilizer

Laird Harrison


May 26, 2015

In This Article

The Letter Every Doctor Dreads

One of the most important lessons Ruth Williams, MD, has learned about the practice of ophthalmology in recent years is to open her mail.

Throwing away what looks like junk can mean missing important news—like the fact that a major health plan is offering incentives to steer patients away from your practice. "The physicians don't even know this is happening because the information comes in a preprinted envelope," says Dr Williams.

Dr Williams, president of the Wheaton Eye Clinic in Wheaton, Illinois, says every physician in the practice recently received such a letter from UnitedHealthcare. It stated the physicians did not meet the "cost and quality designation," Dr Williams says.

As a consequence, the insurer was charging higher copayments for patients of the Wheaton Eye Clinic ophthalmologists than it was charging for some other ophthalmologists in the area.

Such letters are arriving at the offices of physicians throughout the United States. Many have already had the experience of being removed from a patient's network. In these cases, the patients must pay higher out-of-network costs to continue to see them.

Now some insurers are using cost and quality data to sort physicians within networks into tiers with different copayments and deductibles.

Although insurance companies have been "economically profiling" physicians in similar ways for at least 20 years, the practice has accelerated with the implementation of the Affordable Care Act, according to William L. Rich III, MD, medical director of health policy at the American Academy of Ophthalmology (AAO). "It's really exploded in about the past 5 years," he says.


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