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Aetna ranking letters on the way
In June, Aetna will begin notifying phy- sicians by letter of their latest status in the health plan’s Aexcel tiered network program. The rankings in the cost and quality efficiency rating program are slated to take effect Jan. 1, 2014. The Texas Medical Association also is monitoring the new Aetna Performance Network, which includes select hospitals and links members to physician special- ists affiliated with the designated facili- ties. That network launched in January of this year. Aetna representatives said the clinical performance criteria used in the Aexcel preferred physician network are based on nationally-recognized standards from quality oversight organizations like the National Quality Forum (NQF), the Na- tional Committee for Quality Assurance, and the Centers for Medicare and Medic- aid Services, and from specialty societies like the American Osteopathic Associa- tion and the American College of Obste- tricians and Gynecologists. The Aexcel network includes desig- nated specialists in 12 areas: cardiology, cardiothoracic surgery, gastroenterology, general surgery, neurology, neurosurgery, obstetrics and gynecology, orthopedics, otolaryngology, plastic surgery, urology, and vascular surgery.
The plan says it is making “minor” changes to the program as part of an annual assessment and as a result of feedback from doctors, members, and purchasers. For example, the 2014 pro- posed modifications include removing certain clinical measures that have lost NQF endorsement due to a lack of scien- tific evidence and an NQF update to an asthma medication measure.
Aetna will send letters to all eligible
Aexcel specialists with Aetna’s current and future Aexcel designation. The let- ters will include notice of the opportu- nity for doctors to appeal their rankings and will explain how and when that must be done, Aetna representatives said.
More information about Aexcel is available at
www.aetna.com/plans-ser vices-health-insurance/detail/medical- insurance/aexcel-performance-network-
plans.html.
Physicians who meet the Aexcel net- work criteria and additional measures also are eligible for the Aetna Perfor- mance Network, which includes hospi- tals. Patients who use the network have a lower cost-share. Both the hospitals and specialists are evaluated on addi- tional quality and cost measures. Aetna says the network evaluated “top-performing hospitals” based on ad- verse events and readmission criteria, for example. It also includes 20 different specialists who typically treat at these hospitals, meaning they must also have at least 25-percent utilization at an Aet- na Performance Network hospital. TMA is investigating how Aetna no- tifies and evaluates specialists and their hospital affiliations or privileges status to determine whether they are includ- ed — or excluded — from the network, TMA Director of Payment Advocacy Gen- evieve Davis says. Aetna representatives say the health plan does not offer an appeals process for this network, which also raises a red flag.
TMA continues to monitor both of the performance networks to make sure they comply with a 2009 state law governing physician ranking and tiering programs. TMA won legislation that gives physi- cians the right to appeal their ranking or classification before a health insurance company publishes it or to opt out of a program completely. Plans also must involve actively practicing physicians in developing quality standards used. You can find information on physician rankings on the Physician Ranking page of the TMA website (
www.texmed.org/ Physician_Rating_Schemes.aspx). The page includes “Basic Steps for Review- ing and Disputing Physician Rankings & Tierings,” a two-page guide on how to appeal your ranking. n
Amy Lynn Sorrel is an associate editor of Texas Medicine. You can reach her by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at
amy.sorrel@
texmed.org.
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April 2013 TEXAS MEDICINE 49
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