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United Healthcare to alter Premium Designation criteria



May 18, 2015
Area(s) of Interest: Commercial Payors 

The California Medical Association (CMA) has learned that United Healthcare (UHC) has altered the criteria for meeting the physician cost efficiency component of its Premium Designation program. UHC will now designate a physician as “Cost Efficient” when he or she has met the episodic cost benchmark, even if the physician did not achieve the population cost benchmark. The change only impacts those physician specialties that are evaluated on both population cost and episode cost, which include:



  • Family medicine,

  • Internal medicine

  • Pediatrics

  • OB/GYN

  • Allergy

  • Cardiology

  • Endocrinology

  • Nephrology

  • Neurology

  • Pulmonology

  • Rheumatology


Surgical specialties are all excluded.


Previously, physicians who met episodic cost but failed to meet the population cost component did not receive the UHC Cost Efficiency designation in the Premium Designation assessment. The results of the modified criteria were communicated to affected physicians in a letter in March and are also available on the UHC website. This designation includes data from January 1, 2011, through February 28, 2014.


In 2014, CMA raised multiple concerns with the payor’s criteria for evaluating physician cost efficiency and urged the payor to make changes. To read more about the concerns, click here.


Physicians who have questions or concerns with their physician assessment reports or their Premium Designation can contact UHC at (866) 270-5588. Practices that are unable to obtain answers to their questions or resolve the issue with United Healthcare directly should contact CMA at (916) 551-2865.


For more information on the Premium Designation program, visit the United Healthcare website at www.unitedhealthcareonline.com.

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