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Triangle divided in 4 tiers
Triangle divided in 4 tiers

By Martine G. Brousse (still not AI!)

"The Medical Bill Whisperer"

Patient Advocate, Certified Mediator



April 23, 2024


The past few years have seen an increase in plans using a "Tier" system, both in their Pharmacy Directories and for medical services.

How does this work, and why should you care? Is it all about money ?

Let's explore!

A. What is the "Tier" system?

  1. For medical services, it is designed with these goals in mind:

  • insurance members: it is a system of financial incentives to use top-performing providers (for quality of care and better outcomes) at a potential lower cost

  • medical providers: it is a rating system to foster better medical results using less services (such as labs, scans or procedures). The higher the rating, the more patients and therefore increased income.

  • insurance companies: it is a system to get better clinical results at the lowest cost.

2. Pharmacy:

  • The Tier system seeks to choose generic versions or less expensive drugs, away from more prohibitively-priced brand-name prescriptions.

  • The balance of affordability with appropriateness also determines Tier status


B.  How does it work (medical)

  1. The Tier system is the rating by an insurance of every contracted medical provider, including facilities, based on data including cost per diagnosis code, number of auxiliary services used (labs, scans...), length of treatment, outcomes. etc.

  2. The better the outcome (or management of a chronic condition) using fewer services, the higher the rating

  3. Other criteria can be staff efficiency, level of education, professional credentials. For example, a "super-specialist", meaning one with few peers in the state or country or who treats a rare disease, will rate higher than a "regular" specialist

  4. Providers with more general scopes of practice, with less stellar track records, with members' complaints, less time in practice, at a less desirable location, less experienced or skilled, may be rated lower.

  5. How is your care affected? A higher Tier Dr will or should provide better care for less. Your medical condition should be treated with less services, and lead to a quicker or better outcome. For a more complicated diagnosis, a higher Tier physician offers more skills and experience.

  6. Because less auxiliary services are performed, and because the cost to use a higher Tier provider is lower at the time of service, patients will tend to choose those best

  7. However, higher Tier providers are more in demand. You may encounter delays in getting an appointment, more rushed office visits, a busier staff, or difficulty obtaining response, access or action.

  8. While lower Tier providers may not be in such demand, they may be well qualified to treat a condition that is neither difficult nor urgent, and may offer longer visits or other advantages.

C. How does it work (Pharmacy)

  1. The insurance's formulary is the list of every drug (and devices) that are covered as a benefit under your plan. Drugs are divided, usually in 3 tiers, based on criteria such as their cost, availability, proven results and demand.

  2. As your cost varies depending on each tier, it is important to know where your prescription stands. Your pharmacist can help.

  3. A drug can move form Tier to Tier throughout the year, based on:

  • pricing changes

  • new generic options

  • drug shortages

  • increased demand (as we've seen for Ozempic for example)

4. Your insurance must inform you of any change in Tier in advance, so you and your physician can decide whether to continue treatment with the same drug but at a higher cost, or switch to a cheaper option.

D. What to do?

  1. Consider your options: is paying a few dollars more for a more convenient appointment with a lower tier provider worth your time, especially if your need is benign? Do you trust your current physician no matter the Tier? Will your condition require expertise and specialized skills? What is important when picking a PCP or specialist?

  2. Do more research: while your insurance rating system is set mostly toward cost containment, it may not always reflect patients' experiences. A Tier 1 physician or facility showing poor customer service skills, with negative Yelp reviews, having issues getting their Billing right, or with an unresponsive or unprofessional staff, may lead someone elsewhere, even if the Tier is lower and cost (slightly) higher.

  3. For Rx: ask your physician when prescribed a brand-name or expensive drug: Is there a cheaper or generic alternative?

  4. If there is no alternative, or if the prescribed drug is the only one you should take, ask your physician to file a request for "Tier exception". Some good reasons include:

  • medical necessity, or harmful if switched to other version/drug

  • allergy to approved or cheaper versions

  • interference with other drugs

  • other (cheaper) versions tried and failed

  • shortage of the cheaper version With documentation, this request should be approved.

  1. As with so many things in healthcare, a little time and research can save you money.

Blindly trusting an insurance rating is one thing, but other patients' experiences might useful in your decision-making process.

2. Your insurance will note that all its contracted providers are screened and vetted, qualified and in good professional standing, regardless of their Tier assignment.

3. Physicians are not privy to insurance coverage, benefits, costs to you or "tiers". Do help them - and your wallet - by directing your care and prescriptions to options that are as effective but less costly to you.

4. "Do I need it?" "is there an alternative?" "what is the goal?" are always good questions to ask. You are not doubting your physician's medical know-how, but only making sure that bankruptcy is not part of the treatment. Every provider should be sensitive to this.


Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.


(424) 999 4705 - F (424) 226 1330

@martine brousse 2024 @ the medical bill whisperer 2024


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