Author Topic: United Health Care Gives Provider Unfavorable Rating  (Read 819 times)

Michele

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United Health Care Gives Provider Unfavorable Rating
« on: January 29, 2014, 09:41:23 AM »
OK, I'm looking for some other opinions on this.

I have a provider in Washington DC area who received an unfavorable rating from UHC.  This shows up on their website:

"Quality & Did Not Meet
Cost Efficiency"


He has very few UHC patients.  On the reconsideration request there are only 11 patients and most are UNDER the average cost per patient.  He is concerned about that information being out there about him.  We requested a reconsideration but it remained unchanged after the request. 

Is anyone else running into this?  I was thinking he should remove himself from UHC so that he doesn't get booted by them.  He wants to be able to say that he's never been booted from any insurance panel.


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PMRNC

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Re: United Health Care Gives Provider Unfavorable Rating
« Reply #1 on: January 29, 2014, 12:31:34 PM »
He has very few UHC patients.  On the reconsideration request there are only 11 patients and most are UNDER the average cost per patient.  He is concerned about that information being out there about him.  We requested a reconsideration but it remained unchanged after the request.

Is anyone else running into this?  I was thinking he should remove himself from UHC so that he doesn't get booted by them.  He wants to be able to say that he's never been booted from any insurance panel.

Michele, it depends on WHO rated them and then who rated them to rate them.. LOL  I know sounds confusing but commercial carriers do indeed receive rating standards from NAIC.. there are laws now in place that require carriers to post the ratings as public info. There is a difference between a quality rating and cost efficiency rating.. one is a red flag and bad bad bad (quality) while cost efficiency is based on charges, amount of claims billed not medically necessary, and all of those points and more are tallied up and rated.. NOT by UHC but first by UHC and they have to report to NAIC. Going non par will prevent such ratings in future ONLY in regards to claims not AOB assigned submitted by the provider.  That rating stays until the next rating session upon approval.

What you can do by law is write UHC and ask them to submit the full criteria of review and the formal review appeals process. Do it in writing, send it certified and it's a good idea to cc the provider's attorney to give it a little extra clout.

I know a lot about NAIC review and quality carrier review if you need more help. I used to work in a unit where right before points deduction I got the reports.
Linda Walker
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