decisionhealth Newsletters, Part B News - 2011 Issue 9 (September)
4 ways to ensure physician quality ratings don’t hurt cash flow
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Article Overview
This article is for physician practices, practice managers, and billing or revenue cycle staff who need to understand how private insurer quality ratings can influence business performance. It covers how rating systems are used, why low ratings can affect referrals and negotiations, and the general types of steps practices can take to review, question, or appeal ratings through payer and state-level channels.
Why This Topic Matters
Quality ratings from private insurers can affect patient choice, reimbursement dynamics, and administrative workflow. Understanding the broad contours of these programs helps practices protect revenue and prepare for payer negotiations.
Article Sections
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How plans use quality ratings
Explains the general purpose of private insurer physician rating programs and how they are used by payers to influence patient steering and plan operations.
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Why low ratings are a problem
Describes the business impacts a low rating can have on a practice, including patient volume, copay differences, and contract discussions.
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Strategies to appeal low ratings and minimize the impact on your bottom line
Introduces the practical approaches discussed in the article for reviewing a rating issue, understanding payer appeal pathways, documenting an appeal, and escalating concerns when needed.
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Find out why the rating is low, or why it declined
Covers the importance of examining payer-provided rating information and identifying the general reasons a rating may change.
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Find out how the appeal process works
Summarizes the role of payer appeal mechanisms and external standards that may apply to provider rating disputes.
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Build a case for appeal using as much specific data as possible
Discusses the general need to support an appeal with payer data and other relevant information.
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When payers don’t cooperate, go to the state
Addresses escalation options outside the plan when a payer’s process is limited or nontransparent.
What You Will Learn
- How private insurers may apply physician quality ratings
- Why low ratings can affect a practice’s business performance
- What kinds of payer processes may exist for reviewing or appealing ratings
- How practices can generally organize information for a rating dispute
- When outside escalation may be considered if a payer process is not workable
Who Should Read This
- Physicians
- Medical practice managers
- Billing and revenue cycle professionals
- Provider relations staff
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