Here are some suggestions on how physicians can appeal their GIC
tier designations.
Step 1: Contact Your Health Plan
Immediately.
Ask each plan how tier designation was calculated - whether it
was based on cost, quality, or both.
Ask for detailed cost and quality information for each of your
patients. This will help you determine whether patients and
procedures were properly assigned to you.
Ask for details on your own cost and quality measures.
Step 2: When you get the information, immediately ask
for a meeting with a health plan representative. Ask the
representative to:
Explain each of the categories in your report
Explain how the patients in your report were selected for
you
Explain how the procedures in your report were selected for
you
Ask for details on how the quality measure was
determined
Ask for detail on how each cost measure was determined
Ask for details on how patients with multiple physicians for
the same ETG were assigned to you
Ask the plan how it adjusts for risk
Ask when the plan will notify if it accepted your corrections,
and if the correction resulted in a change to your tier
designation
Step 3: If you find errors in your detailed report, file
an appeal with the health plan immediately. In your
letter:
Start with an affirmative statement that you are formally
appealing your tier designation.
Describe the nature of your practice. Point out where multiple
physicians received different tier designations for treating the
same patient population, and especially if they receive similar
quality and efficiency scores. Point out where your practice
collaborates on patient care, and where differing individual scores
are not credible.
Describe what your patients' concerns are - if they're
confused, angry, and especially if they change physicians,
practices, or if the tier designations motivate them to do anything
that disrupts their care or compromises their access to care.
Point out patients who make your case mix unusual or unique,
and whose care is not adequately adjusted or reconciled in the
report. If there are outliers, point out those out and request that
they be removed from your rating.
Point out costs that are not controlled by you or your
practice. For example, care delivered by others in a hospital, for
a patient whom you admitted.
Point out - and quantify - where your report includes patients
that are not in your care.
Point out - and quantify - where your report includes
procedures that you not do.
Step 4: Send your appeal and your detailed documentation
by certified mail and by e-mail.
You want confirmation from the health plan that it has received
your communication, and when the communication was received.
Step 5: If your appeal is denied, contact the health
plan again for further explanation of why your documentation was
not persuasive.
Step 6: Contact the MMS about your
situation.
Keep us informed about the status of your request, the plan's
response, and the outcome of your conversations. We encourage you
to include copies or attachments of your communications.
Contact us either by e-mailing MDfeedback@mms.org or by
calling Lisa Smith at the MMS Department of Health Policy and
Health Systems at (781) 434-7759.
Step 7: Keep your patients in the loop, especially those
who are covered by a GIC plan.
Educate them about physician profiling programs. Download the
patient fact sheet,
"What You Should Know About Physician Tiering" from the
Massachusetts Medical Society website, and share it with your
patients.
