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Diamond Designation™ Program

Program Year 2022 Overview

The Diamond Designation™ Program evaluates practice groups across 12 specialty areas on quality and cost efficiency. The primary dimension for evaluation is quality of care, which is based on specialty specific measures primarily sourced from third-party organizations. Cost efficiency evaluation is based on medical condition-based episodes of care. Results for both quality and cost efficiency are determined at a provider group level based on the group’s Tax ID number. Individual practitioners inherit the group’s designation results.

The Diamond Designation™ Program aims to assist primary care providers in making more informed decisions for specialty care referrals. PCPs consider many factors when recommending or referring members to another provider. We inform primary care practices that the Program designation results should not be the sole basis of their decision making and the information should only be used as a guide in selecting specialists for the care of members. All other relevant information should be considered in the decision-making process. The designation results are not displayed to members within our provider directories.

Email or fax notifications will be sent to evaluated specialty providers in January 2022 once evaluations are complete. Results will be made available for sharing with the primary care community of providers on April 1, 2022, the Program’s effective date. You may request the results of your evaluation by contacting DiamondDesignation@wellcare.com. Evaluated providers may also request reconsideration of their results before they are shared with primary care providers if such requests are received before March 1, 2022.

Evaluated specialty areas for the 2022 Diamond Designation™ Program include:

Cardiology Neurology
Counseling Orthopedic Surgery
Endocrinology Podiatry
General Surgery Psychiatry     
Gastroenterology Psychology
Nephrology Pulmonology

How Results are Displayed

Quality is the primary dimension for evaluation. Quality designation is reflected by a Diamond DesignationTM Diamond Designation™ Program TM icon. Cost Efficiency ratings are represented by a one- to five-star range and are only displayed if the specialty provider has met the threshold to achieve the quality designation of the Program. The absence of a quality or cost efficiency result should not be construed to suggest that a provider does not provide quality or efficient healthcare services. Reasons a provider may not have results for cost efficiency or quality include but are not limited to:

  • They practice in a specialty that is not evaluated by the Diamond Designation Program; or
  • There is insufficient data to meet minimum sample size requirements for statistical evaluation.

The below materials offer additional detail on the Diamond Designation Program:

If you have feedback, questions, or need assistance, you may reach the Diamond Designation Team at DiamondDesignation@wellcare.com.
Complaints? If your patients have a complaint about the Diamond Designation™ Program, they may register a complaint with us.

Important Notes about the Diamond Designation Program

The Diamond Designation™ Program aims to assist primary care providers in making more informed decisions for specialty care referrals based on standard methods in evaluating quality and cost efficiency. Quality is emphasized over cost efficiency in the evaluation process. Primary care providers are informed that determinations from the Program should not serve as the sole basis for specialist provider selection. We evaluate specialty provider quality and cost efficiency for in-network providers at a practice group level based on tax identification number. The current Program evaluates 12 specialty types: cardiology, counseling, endocrinology, gastroenterology, general surgery, nephrology, neurology, orthopedic surgery, podiatry, psychiatry, psychology, and pulmonology.

Information from the Diamond Designation™ Program is not an endorsement of any provider or their delivery of care. Physicians are solely responsible for evaluating the needs of our members and directing them to the most appropriate healthcare services. The Diamond Designation™ Program does not certify the quality of care nor the cost efficiency of care that members receive from evaluated providers. Determinations from the Diamond Designation™ Program are only a partial evaluation of cost efficiency and quality and should not solely serve as the basis for specialist provider selection. Participating specialists are not agents of Wellcare and are solely responsible for the treatment and outcomes of their patients. Physicians participating in our networks have met specific minimum credentialing requirements. Wellcare members continue to have access to all physicians in our network according to their benefit plan and in no way are limited to certain providers based on evaluations under this Program.

The Diamond Designation™ Program methodology for evaluation is based on national standards and incorporates feedback from physicians and other clinicians. Although there is the risk of error in evaluations, Wellcare aims to produce evaluation results that are as accurate as possible. Specialty provider groups evaluated within the Program may request a change or correction to information used to determine their cost efficiency or quality scores. The absence of any quality or cost efficiency determination should not be construed to suggest that a provider does not provide quality or efficient healthcare services. Reasons a provider may not have a determination available for quality or cost efficiency include but are not limited to: 1) they practice in a specialty that is not evaluated by the Diamond Designation™ Program; or 2) there is insufficient data to meet minimum sample size requirements for statistical evaluation.

For the 2022 Program year, research was performed to identify and address COVID-19 impacts to evaluation results. The methodology used to evaluate specialists within the Diamond Designation™ Program is subject to change from year to year.

The information contained in this Program Overview is subject to change.

 

 

Wellcare offers a range of Medicare products, including Medicare Advantage and Medicare Prescription Drug Plans. Wellcare is also affiliated with local plans dedicated to serving Medicaid members in NJ, HI, and KY. The information presented here is representative of our network of products. If you have any questions regarding the different health plans within a state, please contact your dedicated Provider Relations representative.

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Last Updated On: 1/25/2022