02-031 C.M.R. ch. 380, § 5 - DISCLOSURE OF PROVIDER PROFILING DATA

1. Initial Disclosure

A. Required disclosure. At least 60 days before using or publicly disclosing the results of a provider profiling program, a carrier shall disclose to providers:

(1) The methodologies, criteria, data, and analysis the carrier uses to evaluate provider quality, performance, and cost, including but not limited to unit cost, price, and cost-efficiency ratings. A carrier satisfies the requirements of this Subparagraph by describing the data used in the evaluation, the source of the data, the time period subject to evaluation, and, if applicable, the types of claims used in the evaluation, including any adjustments to the data and exclusions from the data;

(2) All ratings and other profiling information specific to a provider that will be posted on the Internet or otherwise disclosed to plan enrollees or prospective enrollees.

B. To whom disclosure is made. The carrier shall provide the disclosures required by this Rule to each facility, practice group, or individual practitioner specifically identified by the carrier in the provider profiling program.

C. Newly added providers. The initial disclosure required by this Subsection shall also be made to any provider that is added to an existing profiling program, at least 60 days before the carrier uses or publicly discloses the new provider's profiling results. The requirement to provide disclosure to newly added providers only applies when the individual provider is profiled, not when the provider joins a practice that has an existing profile.

D. Supplemental disclosures of changes. A supplemental disclosure of all material changes to the initial disclosure shall be made:

(1) To all affected providers, at least 60 days before the implementation of any changes to the methodologies and criteria disclosed pursuant to Paragraph A; and

(2) To any provider whose publicly disclosed profiling results are changed, at least 60 days before the changes are disclosed to the public.

2. Additional Disclosure upon Request

A. Request for data. A provider may request a copy of its data within 30 days after receiving the carrier's initial or supplemental disclosure under Subsection 1. The provider's request must be sent to the carrier in writing, either electronically or by mail. The carrier shall provide the data associated with the requesting provider and all adjustments to the data used to evaluate that provider as part of the carrier's provider profiling program.

B. Acknowledgment. Within 10 days after receipt of a provider's request for additional information, the carrier shall acknowledge the request and explain any objection to the request. Objections to the request must be in writing.

3. Requests for clarification. The provider may make reasonable requests for clarification and correction. If so requested, the carrier must:

A. Give the provider an opportunity to clarify or correct erroneous data or analysis.

B. Respond with a disclosure of additional information including:

(1) The provider's own data relied upon to establish the provider's profile;

(2) A description of the standards or baselines against which the provider's data is being compared in connection with the provider profiling program; and

(3) To the extent applicable, a detailed description of the documented process and methodology used in comparing the provider's data, including but not limited to:

(a) The providers measured, including specialties and geographic areas;

(b) The criteria for inclusion and exclusion in any element of a formula used in calculating each performance measure;

(c) The attribution of patients to providers;

(d) For quality: the minimum number of observations for each measure for assessment of physicians, practices, or medical groups;

(e) The consideration of measurement error in recording actual performance differences among providers;

(f) The peer groups used for comparison;

(g) The consideration of risk adjustments to make comparisons, including differences in the health of patient populations;

(h) For cost, resource use, or utilization: The measurement and treatment of data outliers with respect to quality, cost, or cost efficiency.

Drafting Note: Subparagraph 3 was derived from NCQA 2103 Physician Hospital Quality (PHQ) Standards and Guidelines, Element C "Define methodology," at page 46-47.

4. Responses to requests. Carriers must respond to requests for correction within 30 days. Responses to requests denied in whole or in part must include at a minimum:

A. Documentation of the basis for the carrier's conclusions;

B. The specific reasons for the carrier's decision;

C. Notice of any appeal right available to the provider; and

D. A description of the carrier's ongoing process by which additional information or data can be provided in response to requests for corrections or changes.

5. Notice of Right to Dispute or Appeal. The disclosure required in Subsection 1 must include prominent notice to the provider of any time limits for notifying the carrier that the provider intends to review, dispute, or appeal the provider profile. The time limit shall not be less than 30 days. The requirements of Subsections 2 through 4 may be incorporated into any appeal process established by the carrier in compliance with the appeal requirements of 24-A M.R.S.A. §4303-A(4), except that the carrier must allow for a separate appeal of its response to the provider's request for clarification and correction under Subsections 3 and 4.

Notes

02-031 C.M.R. ch. 380, § 5