The UnitedHealth Premium program provides physician designations based on quality and cost-efficiency criteria to help members make more informed choices about their medical care.
Physicians may also use these designations when referring patients to other physicians. In markets where tiered benefit plans are available, employers may choose to offer their employees a tiered benefit plan with a lower member cost share for using Premium Care Physicians.
The UnitedHealth Premium program evaluates physicians annually, using updated quality and cost efficiency methodologies and data. For the current version 13 release, the Premium program uses claims submitted and processed for dates of service prior to the President’s proclamation declaring the COVID-19 national public health emergency.
Last Published 05.20.2021
We have updated methodology from our website, UnitedHealthPremium.UHC.com. Please view the updated methodology, which is Version 13 of the program, by clicking on “Premium Methodology.” You can review the full document online, choose a section to read or download a PDF version.
Last Published 05.20.2021
Attribution methods based on health plan claims data determine which physicians are responsible for care given to patients.
Last Published 05.20.2021
The Premium program is available for commercial products in 45 states.
Last Published 05.20.2021
For both the quality and cost-efficiency measurements, the Premium program compares the physician’s performance to a case-mix adjusted benchmark. Case-mix adjustment accounts for variations in the composition of the patients and cases each physician treats. The Premium program uses severity adjustments for certain quality measures and patient episode cost measurement, and risk adjustments for patient total cost measurement.
Last Published 05.20.2021
The Premium program uses a five-step process to evaluate the physician’s cost efficiency performance and assigns a cost efficiency rating.
Last Published 05.20.2021
Use this document with the UnitedHealth Premium Program Methodology document at UnitedHealthPremium.UHC.com. Please review all methodology documents to understand the entire Premium program methodology. There are two measurements applied for the evaluation of cost efficiency: • Patient total cost measurement • Patient episode cost measurement The Premium program uses the cost measurement applicable to the physician’s Premium specialty.
Last Published 05.20.2021
The Premium program excludes patient and episode cost outliers in the cost-efficiency evaluation.
Last Published 05.20.2021
The UnitedHealth Premium program provides physician designations based on quality and cost efficiency criteria to help members make more informed choices for their medical care. Physicians may also use these designations when referring patients to other physicians. In markets where tiered benefit plans are available, employers may offer employees a tiered benefit plan based on Premium designation with a lower member cost share for using Tier 1 Premium Care Physicians.
Last Published 05.20.2021
The Premium program’s cost efficiency evaluation compares a physician’s cost efficiency performance to physicians in the same Premium specialty and geographic area. Geographic areas are specialty-specific and are assigned based on the physician’s Premium specialty and primary place of service zip code. The geographic areas are established through a four-step process.
Last Published 05.20.2021
The UnitedHealth Premium program provides physician designations based on quality and cost-efficiency criteria to help members make more informed choices for their medical care. Physicians may also review these designations when referring patients to other physicians. In markets where tiered benefit plans are available, employers may choose to offer their employees a tiered benefit plan, which may provide an enhanced benefit in the form of lower member cost share for seeing a Premium Care Physician.
Last Published 05.20.2021
Patient episode cost reflects a combination of resource utilization, resource mix and unit cost. Episodes include services delivered to a patient related to a specific procedure or treatment of a condition. Services may include those provided by other health care professionals as well as facility, pharmacy and ancillary services (e.g., diagnostic tests). Episodes are categorized as condition or procedure.
Last Published 05.20.2021
Patient total cost is the risk adjusted total cost per month for a patient. This includes services from episodes for conditions relevant to thescope of practice for the physician’s Premium specialty. Patient total cost is risk adjusted by dividing the patient’s total cost per monthby the patient’s risk score, which is based on the patient’s conditions and demographic characteristics. Only patients with at least sevenmonths of eligibility during calendar years 2018 and/or 2019 are included.
Last Published 05.20.2021
The Premium program evaluates physicians in 16 premium specialties representing 47 credentialed specialties.
Last Published 05.20.2021
The Premium program uses a four-step process to evaluate the physician’s quality performance.
Last Published 05.20.2021
The Premium program includes National Committee for Quality Assurance (NCQA) and Bridges to Excellence (BTE) recognition programs in the quality evaluation. The Premium program adds 25 measures or 10% of the physician’s total measures ‒ whichever is larger ‒ as compliant measures, to the quality evaluation for physicians who have achieved recognition in one or more of these programs applicable to their Premium specialty.
Last Published 05.20.2021
The UnitedHealth Premium program provides physician designations based on quality and cost efficiency criteria to help members make more informed choices about their medical care. Physicians may also use these designations when referring patients to other physicians and to support their efforts to provide quality and cost-efficient care to their patients. Specific states have requirements governing physician measurement programs that are different from other standard UnitedHealth Premium program processes. In these states, the Premium program may follow different or additional processes for physicians who are evaluated by the program.
Last Published 05.20.2021
The UnitedHealth Premium program applies statistical tests to determine if there is a statistically significant difference between the physician’s performance and the target benchmark. When there are a sufficient number of quality measures attributed, the chi- square goodness of fit test (for statistical significance) and the phi coefficient (for effect size, or absolute difference) are used to determine if the physician’s performance isn’t statistically less than the target benchmark. When there are a sufficient number of patients and/or episodes attributed, the Wilcoxon rank-sum test is applied to determine if the physician’s performance is statistically less than the target benchmark.
Please see Premium Program News on UnitedHealthPremium.UHC.com
The UnitedHealth Premium reconsideration process allows physicians to request a correction or change to certain quality and/or cost-efficiency information included in their Premium evaluation. If the COVID-19 national public health emergency has affected the amount of time you need to review and request reconsideration of your results, please contact us for an extension to your reconsideration due date.
For more information on requesting reconsideration, please click here.
The Premium program consists of both quality and cost-efficiency evaluations. Quality is the primary program measurement and is assessed using national standardized measures. Cost efficiency is evaluated using two measurements: patient total cost and patient episode cost. The physician’s Premium specialty determines which measurement is applied.
The program evaluates physicians annually using updated quality and cost-efficiency methodologies and data. Physicians receive their designations based on a comparison of current version and previous version evaluation results.