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

Laird Harrison


May 26, 2015

In This Article

Being Profiled as a High Utilizer

Many private insurers use third-party "episode grouper" software that aggregates data from pharmacies and outpatient and inpatient care, then compares costs of treating episodes of illness among physicians, Dr Williams says. In theory, the software also incorporates information about the quality of care, but in reality insurers don't collect much quality data beyond patient satisfaction surveys, Dr Williams says.

Most private insurance companies provide little public information about the software they use, and in general how they profile physicians. Representatives of UnitedHealthcare, the Blue Cross and Blue Shield Association, and America's Health Insurance Plans did not return phone calls. Queries to four other plans went unanswered.

UnitedHealthcare offers sample tiers and rates for physicians to members of its North Shore-Long Island Jewish Hospital Advantage plan in in Queens, Nassau, and Suffolk counties in Long Island, New York (Table).

Table. Sample Tiers and Rates for UnitedHealthcare's North Shore-Long Island Jewish Hospital Advantage Plan[1]

Tier Primary Care Physician Copayment Specialist Copayment In-Network Coinsurance In-Network Maximum Out of Pocket Cost Emergency Department Copayment
Tier 1 $30 $250 10% $1000 $200
Tier 2 $100 $500 30% $2000 $200

In an email, Aetna spokesperson Sherry Sanderford says that her company assigns ophthalmologists and other physicians in its Performance Network to tiers on the basis of the hospitals they use. If the ophthalmologists don't use hospitals much, or they use tier-1 hospitals, they are sorted into tier 1. If they use tier-2 hospitals, they are sorted into tier 2 themselves.

Besides cost efficiency, Sanderford says, Aetna rates hospitals on the basis of adverse events; 30-day hospital readmissions; average length of stay compared with expected averages; data from the Centers for Medicare & Medicaid Services (CMS); and "cost efficiency" compared with other hospitals in that market.

Similar to UnitedHealthcare, Aetna Performance Network patients pay $500 deductibles for both tier-1 and tier-2 doctors in-network, and $1000 deductibles for physicians who are out of network. They pay 20% of their remaining bill in tier 1, 40% in tier 2, and 50% out of network.

"Aetna Performance Network encourages members to think differently about healthcare spending and approach it like a consumer would consider any important financial decision—by becoming educated about their options and comparing costs before making a thoughtful decision," Sanderford says.


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