Payers have various rating, tiering, and ranking systems that attempt to assess a physician's performance against his or her peers. Some of these systems may be tied to reimbursement rates, but mostly they are used to steer patients to physicians in the higher-quality tier.
Often, say critics, the criteria on which the ratings are based are not disclosed to physicians in advance—when they could make changes to their practice. Moreover, many providers and consultants say the ratings are often incorrect, or at least imprecise. They also say the ratings may have more to do with cost than quality.
These rankings are an increasingly important part of marketing for health plans, so it's unlikely you will be able to opt out of them, says Jeffrey B. Milburn, Colorado Springs–based independent consultant at MGMA Health Care Con-sulting Group. But you can probably include provisions in your contract to help ensure accuracy. Milburn says such provisions should include:
If you think the data are incorrect, ask for a meeting. "I haven't had anyone turn me down. If the representative is reluctant to meet, appeal to the plan's medical director," says Milburn. If the plan is unwilling to give you that access, you may have a problem.