In November 2015, United Healthcare (UHC) sent notice to 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 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) medications
  •     Tier 3 (highest cost sharing) 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 states 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 phase of the program.

UHC states that 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 physician_engagement@uhc.com.

For further questions or assistance, contact the ACCMA at 510-654-5383 or accma@accma.org.