United tells doctors if they're coding for more than their peers

The plan views its coding communication as helpful sharing of information, but some physicians see a subtle attempt to encourage downcoding.

By Tyler Chin, AMNews staff. Sept. 12, 2005.

Over the past year, UnitedHealth Group has been increasingly informing primary care physicians that their coding of certain high-intensity evaluation and management services surpasses their peers' average, and that their contracts could be terminated if their coding fails to move in line within three to six months.

Retrospective claims review of physicians' billing by insurers is not new, nor is it limited to United. But physicians can expect to see a lot more of it in the future, said Ray Herschman, national consulting practice leader at Mercer Health and Benefits Consulting in Cleveland.

"In general, the whole area of [physician] performance measurement is the new frontier in medicine. There's no question that it's absolutely where the market is going. It's in three areas, and they are evolving at different speeds. The first one is cost. The second one is in clinical quality, and the third one is in the area of patient experience," Herschman said.

One big driver fueling the activity is that technology enabling plans to measure those areas are improving, Herschman said. Another, he said, is that plans believe there are great variants among physicians in treating the same conditions, and billing similar amounts for doing so.

"Our role is to provide data on variation, to share that information with physicians, to help inform them what the sources of variation are or identify areas to have a dialogue around ... and use that as a basis to support physicians in improvements, as they see fit," said Lewis Sandy, MD, executive vice president for clinical strategies and policy at United, the nation's second-largest private-pay health plan, after WellPoint.