State Law

Maryland Statutes-Article 15. Insurance

08/07/2023 Maryland Sections 15-1701 through 15-1704

Sections concerning physician profiling


Section 15-1701

(a) In this subtitle the following words have the meanings indicated.

(b) “Carrier” has the meaning stated in § 15-1301 of this title.

(c) “Enrollee” means an individual entitled to health care benefits from a carrier.

(d)  “Physician rating system” means any program that:

(1) measures, rates, or tiers the performance of physicians under contract with the carrier; and

(2) discloses the measures, rates, or tiers to enrollees or the public.

(e) “Ratings examiner” means an independent entity that is approved by the Maryland Health Care Commission to review physician rating systems.


Section 15-1702

(a) A carrier may not use a physician rating system unless the physician rating system is approved by a ratings examiner.

(b) A carrier shall contract with and pay for a ratings examiner to review any physician rating system of the carrier.

(c) A physician rating system of a carrier is deemed to meet the requirements of this section if the physician rating system:

(1) is approved by a ratings examiner as of January 1, 2010; and

(2) notwithstanding any revisions to the physician rating system, maintains its approval by the ratings examiner.


Section 15-1703

(a) A carrier that uses a physician rating system shall:

(1) establish an appeals process for physicians to use to contest their rating; and

(2) at least 45 days before making available to enrollees any new or revised quality of performance or cost-efficiency evaluations or any new or revised inclusions or exclusions from a physician rating system, provide each physician included in the physician rating system with:

(i) a notice of the proposed change;

(ii) an explanation of the data used to assess the physician and how the physician may access the data;

(iii) the methodology and measures used to assess the physician;

(iv) an explanation of the right to contest the rating of the physician through the appeals process of the carrier; and

(v) instructions on how to file a timely appeal with the carrier.

(b) If a physician files a timely appeal, as defined by the carrier, regarding the rating of the physician under a physician rating system, the carrier may not disclose the rating of the physician or make a change in the quality of performance or cost-efficiency ratings of the physician until the carrier completes its investigation and renders a decision on the appeal.

(c) A carrier shall post the following information prominently on the section of the carrier’s Web site that discloses the rating of a physician to enrollees or to the public:

(1) where an enrollee can find the physician performance ratings of the carrier;

(2) a disclosure that physician performance ratings are only a guide to choosing a physician because the ratings have a risk of error and should not be the sole basis for selecting a physician;

(3) an explanation of the physician rating system, including the basis on which physician performance is measured and the basis for determining that a physician is not currently rated due to insufficient data or a pending appeal;

(4) any limitations of the data that the carrier uses to measure physician performance;

(5) the factors and criteria used in the carrier’s physician rating system, including quality of performance measures and cost efficiency measures; and

(6) how a physician may appeal a physician rating.


Section 15-1704

(a) A carrier shall notify the Commissioner of the results of any final review conducted by a ratings examiner of a physician rating system of the carrier within 45 calendar days after receipt of the results by the carrier.

(b) If the review conducted by a ratings examiner of a physician rating system of a carrier indicates that the physician rating system does not comply with the requirements of Title 19, Subtitle 1, Part V of the Health – General Article, the Commissioner may order the carrier to:

(1) correct the deficiency; or

(2) cease the use of the physician rating system.

(c) A carrier using a physician rating system shall report annually to the Commissioner:

(1) the number of appeals filed by physicians under this subtitle; and

(2) the outcome of the appeals.