Section 19-147 - Ratings examiners.
§ 19-147. Ratings examiners.
(a) Approval by Commission.- The Commission shall approve an entity that meets the requirements of this section to be a ratings examiner.
(b) Requirements of physician rating systems.- To be approved by the Commission as a ratings examiner, an entity examining a physician rating system shall require a physician rating system to:
(1) Use only quality of performance and cost efficiency as measurement categories;
(2) Calculate and disclose separately measures of cost efficiency and quality of performance;
(3) Disclose clearly to physicians and enrollees the proportion of the component score for cost efficiency and quality of performance in each combined score;
(4) In determining quality of performance, use measures:
(i) That are based on nationally recognized, evidence-based or consensus-based clinical recommendations or guidelines; or
(ii) When available, that are endorsed by entities whose work in physician quality of performance is generally accepted in the health care system;
(5) Disclose to physicians who are subject to the physician rating system:
(i) The measurements for each criterion and the relative weight of each criterion and measurement in the overall rating of the physician;
(ii) 1. The basis for the carrier's quality of performance ratings;
2. The data used to determine the quality of performance ratings; and
3. The relative weight or relevance of quality of performance to the overall rating of a physician in the physician rating system;
(iii) The basis for determining whether there is a sufficient number of patients and episodes of care for a given disease state and specialty to generate reliable ratings for a physician; and
(iv) The methodology used to determine how data is attributed to a physician;
(6) Use appropriate risk adjustments to account for the characteristics of the patient population seen by a physician in determining the quality of performance and cost efficiency of the physician;
(7) In measuring the cost efficiency of the performance of a physician:
(i) Compare physicians within the same specialty within the appropriate geographical market; and
(ii) Use appropriate and comprehensive episode of care computer software to evaluate the cost efficiency of the performance of a physician;
(8) (i) Include an appeals process that a physician subject to the physician rating system may use to appeal the rating received under the physician rating system; and
(ii) Based on the outcome of an appeal, make any necessary corrections to the data used to rate the physician in the physician rating system; and
(9) Disclose to physicians and enrollees how the perspectives of enrollees, consumer advocates, employers, labor unions, and physicians were incorporated into the development of the physician rating system.
(c) Programs approved after August 1, 2008.- Notwithstanding subsection (b) of this section, an entity that has a physician performance rating certification program approved after August 1, 2008, by a national consortium of employer, consumer, and labor organizations working toward a common goal to ensure that all Americans have access to publicly reported health care performance information:
(1) Is deemed to be a ratings examiner under this part; and
(2) Is deemed to meet the requirements of subsection (b) of this section.
[2009, chs. 585, 586.]