January 12, 2016
Area(s) of Interest: Payor Contracting Payor Issues and Reimbursement Practice Management
United Healthcare (UHC) recently notified approximately 800 contracted primary care physicians, introducing them to its new educational performance evaluation program. Slated to run concurrently with the UHC Premium Designation program, primary care physicians whose claims data demonstrates a high utilization rate in one of the following measures will receive a performance evaluation report:
- Emergency department utilization
- Inpatient admission utilization
- Average length of stay
- Laboratory/pathology utilization
- Levels 4 and 5 visits
- Modifier 25 utilization
- Modifier 59 utilization
- UHC premium non-tier 1 specialist visits
- Out-of-network costs for attributed patients
- Specialty physician utilization
- Radiology utilization
- Prescribing of Tier 3 (highest cost sharing tier) medications
- Tier 3 (highest cost sharing tier) pharmacy utilization by other treating physicians of attributed patients
The initial letters were mailed to physicians on November 17, 2015, and reflect a 12-month review period beginning with January 2014 dates of service. While the notice indicates that the purpose of the program is to identify and address variations in care, UHC says that the review is only informative and intended to provide feedback on the performance of the practice. According to the payor, approximately 5 percent of contracted physicians will receive a letter in this first iteration of the program.
Future phases of this program will incorporate additional specialties including obstetrics/gynecology, cardiology, neurology, orthopedics, spine and surgery.
For additional information or questions regarding this program, view the UHC FAQ or contact the UHC Health Care Measurement Resource Center at (866) 270-5588 or firstname.lastname@example.org.