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

Laird Harrison


May 26, 2015

In This Article

What to Do if You're Unfairly Profiled

Physicians don't have to take their designations lying down, says consultant Reed Tinsley. "You appeal it," he says. "You sit down and say, 'Tell me how you graded me, and I want to see the data you used,' and compare. Insurance companies make mistakes, like anybody else."

The Wheaton Eye Clinic appealed its physicians' new designations through a process outlined in the UnitedHealthcare letter. The insurer changed the status of all but three physicians to "not enough data to assess." One key to the success of the appeal was developing a personal relationship with someone at UnitedHealthcare, Dr Williams says.

Still, UnitedHealthcare continues to charge a higher copayment for three physicians focused on glaucoma, and Dr Williams thinks that the insurer doesn't take into account the resources demanded for that disorder.

Some other glaucoma subspecialists have succeeded in their appeals, Dr Rich says. It's helpful to show the payer the percentage of patients who have glaucoma and include codes designating different stages of open-angle glaucoma to show the severity of the patients' condition, he says. "Sometimes those letters are very effective; sometimes they're not."

The pediatric subspecialists in Northern Virginia Ophthalmology succeeded in getting reinstated, says Dr Rich. "They wrote long, painful appeals and enlisted the support of local pediatricians."

Dr Rich and Dr Williams both urged ophthalmologists to keep track of claims data and quality benchmarks, such as the IRIS Registry, to prepare for such conversations.

The American Glaucoma Society and AAO both have developed materials to use in communicating with payers on this issue.


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