DocFind

Information About Aexcel® Specialists

The blue star on the results page identifies specialists who meet certain clinical performance and cost-efficiency standards. These specialists are Aexcel designated.

You'll find Aexcel-designated specialists in these categories:

Cardiology	Neurology	Otolaryngology/ENT
Cardiothoracic Surgery	Neurosurgery	Plastic Surgery
Gastroenterology	Obstetrics and Gynecology	Urology
General Surgery	Orthopedics	Vascular Surgery

Click here to learn more about Aexcel sub-specialty categories.

The Aexcel designation

Aexcel is a designation for specialists who are part of the Aetna broader network and who have met certain clinical performance and cost-efficiency standards. In our evaluation process we complete several steps resulting in a performance network that includes specialists in the 12 Aexcel specialty categories. As a result of this evaluation, we identify a network that displays any specialist who does satisfy the Aexcel standards with a blue star.

A full explanation including a detailed methodology overview, a complete list of evaluation criteria, explanations of risk-adjustment, patient to doctor attribution, statistical significance applied during evaluations and much more is available on our public website. The Learn More page provides only a high-level overview of the Aexcel evaluation process.

Aexcel information we offer you is intended to be only a guide for when you choose a specialist within the Aexcel specialist categories. There are many ways to evaluate doctor practices and you should consult with your existing doctor and the specialist who you are selecting before making a decision. Please note that all ratings have a risk of error and, therefore, should not be the sole basis for selecting a doctor.

Please consider the following when selecting a doctor:

Consult with your doctor regarding your health care decisions
View specialist clinical quality and cost efficiency information as one factor in your health care decision
Aexcel designation is not a guarantee as to the quality of the service you receive or the outcome of any treatment by that specialist
If a specialist is currently not designated for Aexcel:
- this does not mean the doctor does not provide quality services
- we might not have sufficient data to evaluate this doctor
- this doctor might be in the process of appealing their status; and/or
- this doctor's specialty is not one of the 12 Aexcel specialty categories

We value your input. Please provide us with your feedback by completing a brief survey. Please see the Complaints and Appeals section if you want to register a complaint about Aexcel.

How we designate specialists for Aexcel

We begin our evaluation by identifying doctors and groups within our network in the 12 specialty areas mentioned before.

Physicians must have a minimum volume of episodes of care and pass clinical performance criteria to be considered for Aexcel designation.

All physicians are included in the clinical performance evaluation using 5 categories of measures. One of these categories is claim-based measures. A physician must have at least 10 Aetna cases for each applicable measure to be evaluated.

For evaluation of efficiency, we identify specialists/groups currently participating in Aetna’s network who have managed at least 20 episodes of care for Aetna members over the past 3 years.

Clinical performance standards

We use standards that are recognized by leading associations in the industry. Doctors may meet clinical quality evaluation standards based on one of the five criteria categories below:

Group must pass at least 1 of the Clinical Performance criteria outlined below
Use of Technology	Alignment with Aetna Institutes of Quality® (IOQ)	Certification by External Entity	Board Certification	Claim-Based Measures
At least 75% of specialists in a group have BTE or NCQA Physician Office Link recognition, or Use of NQF-endorsed healthcare technology measures (example: electronic medical records)	An affiliated physician with Aetna's IOQ facilities with the primary specialty recognized for the IOQ	At least 75% of specialists in a group have NCQA or BTE recognition in Diabetes Care Cardiac/ Stroke Low Back/Spine	At least 75% of specialists in a group must be board certified in their Aexcel specialty. Board eligible physicians do not meet requirements.	Must have at least 10 cases in any given measure Hospital readmission rates after 30 days Rates of health complications during hospital care Other treatments, by specialty, shown to improve outcomes
NQF website at www.qualityforum. org/projects/ ongoing/hit/ BTE website at www.bridgestoexcellence.org	IOQ website at http://www.aetna.com /provider /medical/ resource_med /business_med/ institutes.html	NCQA website at www.ncqa.org/ BTE website at www.bridgestoexcellence.org	ABMS website at www.abms.org/ AOA website at www.osteopathic.org/	All claims-based measures are endorsed by NQF with the exception of rate of readmission and adverse events which are approved by AHRQ and CMS.

BTE (Bridges to Excellence) ; NCQA (National Committee for Quality Assurance); NQF (National Quality Forum)

Claim-based clinical performance measures

For claim-based measures the physician or group must have at least 10 cases in any given measure to be evaluated. The 10 cases can represent unique members or events, depending on the measure. In some measures, such as breast cancer screening, cases are members. In some measures, such as adverse event rate, a case is each event, and a member can have multiple events.

Specialty Category	Clinical Performance Standard*	Recognized Association
Obstetrics and Gynecology	Cervical Cancer Screening rate - How often patients cared for by an Ob/Gyn who should be getting Pap smears are actually getting this test Breast Cancer Screening rate - How often patients cared for by an Ob/Gyn who should be getting mammograms are actually getting this test	ACOG www.acog.org/ AQA www.aqaalliance.org/ NCQA web.ncqa.org/ CMS www.cms.hhs.gov/
Cardiology	Use of beta blocker for patients with history of heart attacks - How often patients cared for by a cardiologist take medications that have been proven to prevent heart attacks in people with heart disease Use of ACE inhibitor or ARB for patients with heart failure - How often patients cared for by a cardiologist take medications that have been proven to effectively treat heart failure Use of ACE inhibitor or ARB for patients with coronary artery disease (CAD) and diabetes - How often patients cared for by a cardiologist take medications that have been proven to effectively treat those with CAD and diabetes Use of cholesterol-lowering medications (statin) for patients with CAD - How often patients cared for by a cardiologist take medications that have been proven to effectively treat high cholesterol in people with heart disease Annual monitoring of ACE inhibitor or ARB - Patients on ACE inhibitor or ARB who had at least one serum potassium monitoring test and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test Annual monitoring of digoxin - Patients on digoxin who had at least one serum potassium monitoring test and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test Annual monitoring of diuretics - Patients on a diuretic who had at least one serum potassium monitoring test and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test	American College of Cardiology www.acc.org/ American Heart Association www.americanheart.org/ CMS www.cms.hhs.gov/ JCAHO www.jointcommission.org/ AQA www.aqaalliance.org/ NCQA web.ncqa.org/
Orthopedics	Osteoporosis management following fracture - Patients age 50 years and older with a fracture of the hip, spine or distal radius who had a central DXA measurement ordered or performed, or pharmacologic therapy prescribed.	AMA PCPI www.ama-assn.org/ama/pub/category/2946.html NCQA web.ncqa.org/
Neurology	Annual monitoring of anticonvulsant therapy - Patients on anticonvulsants who had at least one drug serum concentration level monitoring test.	CMS uses 30-day readmits as a marker for case review. www.cms.hhs.gov/
All Aexcel specialty categories	Absence of an unexpected readmission to a hospital - Measurement used to determine the absence of a patient being unexpectedly readmitted to the hospital within 30 days after being discharged from the hospital. There are complications that occur that would require a patient to be readmitted to a facility after discharge from a hospital. We measure the absence of those readmissions for physicians who are managing the first inpatient stay. Absence of an adverse event - Measurement used to determine the absence of an adverse event during an inpatient hospital stay. Complications can occur during a hospitalization that could be avoided. We look for an absence of complications or adverse events during inpatient stays being managed by a physician.	The adverse event rate/index (number of complications or problems for hospitalized patients) is consistent with AHRQ quality indicators. AHRQ is part of the National Institutes for Health. www.ahrq.gov/

* All claims-based measures are endorsed by the National Quality Forum with the exception of rate of readmission and adverse events which are approved by AHRQ and CMS.

Efficiency standards

Efficiency is a combination of a price paid for services and number and type of services performed. We use methodology based on episodes of care, which is the current industry standard for measuring efficiency.

When looking at the resources used when treating Aetna members in the Aexcel specialty categories - all services associated with the specialist visit are taken into account, not just visits to the specialist's office. The review includes inpatient, outpatient, diagnostic, laboratory and pharmacy claims for patients of these specialists.

We make sure that we accurately match the care provided to a patient with the right doctor who was most critical in delivering that care, a concept known as attribution. For clinical measures, attribution logic is specific for each measure. For cost-efficiency measures, surgical episodes are credited to the surgeon with the highest allowed charges. If the episode is non-surgical, the physician with the highest number of visits receives the attribution of the case.

We apply risk adjustment factors to account for differences in use of health care resources used by different patients, accounting for, age, gender, chronic disease risk, insurance product type and year the services were paid for.

In addition, we compare all the resources used to treat a specialist’s patients to those of other specialists in the same specialty and geographic location. If a specialist is a part of a group, we evaluate the entire group. In this case, performance measurement results of other doctors in the group will have an impact on each individual doctor’s evaluation.

We use statistical significance when reviewing efficiency to increase the confidence of the performance evaluation decisions. A result is described as statistically significant when it can be demonstrated that the probability of obtaining it by chance only is relatively low.

Network Access

After we complete our evaluation, we make sure that the resulting performance network is broad enough and includes a sufficient number of Aexcel designated specialists to meet the needs of our members. Network access standards vary by state and depend on population density in a given area. We may add specialists to the network to make sure members have satisfactory network access to Aexcel specialists. We do not add back specialists who were previously excluded because they did not pass the clinical performance standards.

Changes in Designation Status

We re-evaluate specialists’ performance at least every two years. As a result of re-evaluation, new specialists may become Aexcel-designated and some currently designated specialists may no longer meet the criteria for Aexcel. These specialists, however, will remain participating physicians in the Aetna broader network. Depending on your health plan, you may still be covered for care from these specialists, but you may pay more out of pocket. Please check your plan of benefits to be certain of the impact. If you are looking for an Aexcel-designated specialist in your area or want to confirm Aexcel status, visit DocFind®, our online provider directory, at www.aetna.com

Data Limitations

As Aexcel continues to evolve we look for opportunities to further enhance our methodology and evaluation process based on new clinical evidence, feedback from members, providers and employers, as well as evolving industry trends. While we are committed to using the best available information, there are certain data limitations:

The claim-based clinical quality and efficiency information is based on Aetna member data only. We support industry-wide data collection initiatives and when this credible combined data becomes available, we will consider using it in our evaluations.

The claim data used to evaluate physicians does not include all procedures, lab or pharmacy data - only those for which Aetna has claim data. Therefore, we strongly encourage physicians to reach out to us with additional data they might have in medical charts that is not available to us through claims data.

Some providers and provider groups cannot be evaluated for Aexcel designation due to limited Aetna patient encounters. Unless they have at least 20 encounters over a 3 year period, we can not be confident that the resulting evaluation will be accurate.

During the review process, we consider that some doctors may treat patients with more than one health issue or more complex conditions. While we use an industry recognized model, a perfect mechanism that accounts for all variations in patient population still does not exist.

Important Information

The National Committee for Quality Assurance (NCQA) is an independent not-for-profit organization that accredits health care organizations. It also recognizes physicians in key clinical areas.

NCQA serves as an independent ratings examiner for Aetna. It reviews how Aetna’s Aexcel program meets criteria required by the State of New York and the Patient Charter. The Patient Charter was developed by the Consumer-Purchaser Disclosure Project. It is a group which includes leading consumer, labor and employer organizations. They are working toward a common goal to ensure that all Americans have access to publicly reported health care performance information.

It is a requirement in the state of New York that NCQA publicly report the results of health plans’ compliance with the New York Attorney General Agreement. View the NCQA’s latest report on our compliance with New York’s requirements.

Complaints and Appeals

To obtain a review or register a complaint:

call our Member Services Department using the telephone number displayed on the member ID card, or
submit a request in writing to the Appeals Resolution Team address shown on your Explanation of Benefits (EOB) or the Member Complaint and Appeal form.

A Member Complaint and Appeal Form is available both on DocFind and Navigator by visiting “Requests & Changes” and selecting “Forms” option. Refer to Understanding Aexcel brochure for more information.

If you are a member in the state of New York, you may also register your complaint with NCQA by sending it in writing to customersupport@ncqa.org or to NCQA Customer Support, 1100 13th Street, NW, Suite 1000, Washington, DC, 20005. NCQA serves as an independent ratings examiner for Aetna, reviewing how Aetna's Aexcel program meets criteria required by the State of New York.