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Physician Data Integrity

Today, data collection is a critical component of most physician practices, especially as physicians consider new types of payment structures that require regular performance analysis.  Physician data are also widely available to patients so that patients can consider quality and costs when making health care decisions.  Meanwhile, researchers and other stakeholders are using physician data to study population health, health care costs and quality of care.  Physicians have a strong interest in ensuring the integrity of this data.

Please contact Emily Carroll, JD, Senior Legislative Attorney, with any questions.

Physician profiling and network determination

Health insurers publically evaluate physicians and other health care providers, frequently placing them into tiered or narrow networks to control resource use and steer patients towards less costly providers.  Patients in a tiered network frequently pay higher co-pays or coinsurance when they see physicians that the insurer has placed in a more expensive tier.  Patients in a narrow network are frequently prevented from seeing and physicians that are deemed too expensive by the insurer and are denied a place in the insurer's narrow network.

The AMA is committed to securing safeguards that protect the accuracy and integrity of physician data used to evaluate physicians.

Learn more about physician profiling and network determination, in the below AMA resources:

Additional information:

Data reports to physicians

Physicians must have access to accurate and useable data to participate in new payment and delivery models, validate or challenge their online profiles and undertake quality improvements.  Currently, health plans each use their own unique format for reporting physician data, making it difficult for physicians to decipher the various reporting formats and understand the data.  Many insurers' data reports also lack sufficient detail to be actionable by physicians.

Access the AMA's "Physician Data Reporting Act" model legislation.  For more information on reporting physician data, view the AMA's "Guidelines for Reporting Physician Data" resource.

All payer claims databases

Currently 18 states either have, or are implementing, an all payer claims database (APCD).  APCDs are potentially valuable sources of data for policymakers, physicians, patients, payers and purchasers of health care if the claims data is accurate and reported in a usable format.  APCDs typically include data derived from medical, pharmacy and dental claims from private and public payers.

As APCDs are established, the ARC is working to make certain that appropriate safeguards are in place to ensure the integrity of the claims data collected and released.

Learn more about states' activities from the APCD Council.