03/02/2016

New York Tiered Payment Program

We have been working with OPEIU Guild 45 and APMA to get a fuller understanding of New York’s tiered payment systems. It appears podiatrists in some insurance networks are being placed in a ranking system  - bottom tier requires a $40 co-payment, the middle tier a $20 co-payment and the top tier requires no co-payment.  Here is what we have discovered:

The New York plans that entered into a tiered payment agreement are having their compliance with the agreement monitored by the National Committee on Quality Assurance (NCQA) to the extent they have doctor ranking programs.  NCQA has the power to revise the standards, but the basic elements are still there. Below are two links to look up the performance of the plans and understand how their tiering programs work.  Click on the plan name and tiering, to see a detailed description of the tiering methodology.  We believe that this is the primary manner in which this information is disclosed.

• http://nyrxreport.ncqa.org/SummaryResults.aspx  Click on the plan for a detailed explanation

• http://nyrxreport.ncqa.org/EvaluationRequirements2013.aspx

The doctor ranking model used in New York called for the following in terms of transparency:

• Plans must apply for and obtain review by the oversight monitor NCQA, to enable reporting of the detailed data and methodologies to doctors in an independent and easily-accessible manner, including measures and other criteria, that the plan used to determine doctor quality and cost-efficiency ratings and inclusion or exclusion in network. In addition, the plan shall explain to the doctor that they have the right to correct errors and seek review of data, quality and cost-efficiency performance ratings and inclusion or exclusion from the network.

• Plans shall also inform doctors they may submit any additional information, including that contained in medical charts, for consideration.

• Plans shall also provide a reasonable, prompt, and transparent appeals process.

• At the time the program is made public, plans shall document that they have already completed or have applied to complete review by NCQA. 

• At least 45 days before making available to consumers any new or revised quality or cost-efficiency evaluations or any new or revised inclusions or exclusions from the network, plans shall provide doctors with notice of the proposed change; an explanation of and access to the data used for a particular doctor; methodology and measures used to assess doctors, including attribution; and an explanation of the doctor’s right to make corrections and appeal. If a doctor makes a timely appeal, the plan shall make no change in the doctor’s quality and cost-efficiency rankings or designation until the appeal is completed.

• NCQA shall have oversight and review of the doctor appeals process.

It’s important to keep in mind that this process is conducted under the authority of state law. Thus, unless plans voluntarily comply, it would not apply to self-insured programs or Federal programs like FEHB, TriCare, or Medicare Advantage.