What Actually Drives Your Malpractice Premium: The 9 Rating Factors Underwriters Use

Malpractice insurance is priced from nine factors: specialty and procedures, venue, claims-made maturity, limits, loss history, FTE, entity and roster, deductible, and credits. Two internists with the same boards can still be thousands of dollars apart. A 2025 Los Angeles internist manual is $8,274 at $1M/$3M. Miami-Dade internal medicine is $59,736. Class mix, step year, and credits then move the invoices again.

Underwriters do not price a generic doctor. They price a written practice description, a courthouse, and a retro date.

The 9 Rating Factors

1. Specialty Class and Procedure Mix

Class is the first cell. Medical Liability Monitor publishes internist, general surgeon, and obstetrician-gynecologist manuals in the series the AMA cites. In 2025, Connecticut ran from $22,467 for internal medicine to $159,537 for OB/GYN. Miami-Dade filed general surgery and OB/GYN at $243,988. Endoscopy, office surgery, cosmetics, pain, and obstetrical call can reclass the file.

2. Venue: State, County, Courthouse

Territory often outweighs specialty inside one class. Los Angeles 2025 manuals: internal medicine $8,274, general surgery $41,775, OB/GYN $49,804. Miami-Dade: $59,736, $243,988, $243,988. Two addresses in one metro can price differently if the county line sits between them.

3. Claims-Made Maturity and Retro Date

Claims-made dominates physician paper. Year one is a slice of the mature rate. The premium then steps, usually over four or five years, until it reaches mature. Occurrence costs more each year because tail is already inside the rate. On claims-made, the retro date is part of the price. A gap, missing tail, or fuzzy start date gets loaded or declined.

4. Limits and Defense Treatment

$1M/$3M is the independent-group default. Higher limits cost more, but not dollar-for-dollar. Shared versus separate limits, and whether the entity has its own tower, change premium and how a claim spends coverage. Defense-inside-limits versus defense-outside-limits is a product difference.

5. Loss History

Open claims, paid indemnity, incident reports, and how hard a prior carrier reserved a file all move the indication. A five-physician independent group has no large-account credibility to dilute one physician's case. Send current loss runs.

6. Full-Time Equivalent and Hours

Part-time credits exist when the carrier files an FTE factor. A 0.5 FTE should not buy a 1.0 cell. Moonlighting, locums days, and a second clinic can push hours back toward 1.0. Underwriters want hours, not a self-label of part time.

7. Entity, Group Size, and Roster

The PC or PLLC needs a limit. Shared entity limits look cheaper on day one and tighter after a suit. NPs and PAs add exposure. MLM's 2025 median NP premium was $2,576, a marker, not your endorsement.

8. Deductible and Retention

A deductible can reduce premium. It can also put defense or indemnity cash on the PLLC, depending on the form. For a small group, treat it as a capital decision, not a coupon.

9. Credits and Debits

Claims-free, risk-management CME, new-to-practice step, association membership, and group-size credits apply only when the application documents them. Debits for late reporting, work outside the described class, or ignored risk-management requirements run the other way.

Worked Example: Two Internists, Two Very Different Quotes

Dr. A and Dr. B finished the same residency eight years ago. Both are board-certified internists. Neither has a paid claim. Both want $1M/$3M claims-made. A recruiter would call them interchangeable. An underwriter would not.

Dr. A. Office-based internal medicine in Los Angeles, 1.0 FTE, no procedures beyond the internist class, mature claims-made, clean retro date, individual policy, claims-free and risk-management credits documented. The 2025 LA internist manual is $8,274. Planning band: low five figures, often near the manual.

Dr. B. Internal medicine on the website. Splits 0.7 FTE in a Florida office and 0.3 FTE on hospitalist shifts plus occasional endoscopy. The Florida site is Miami-Dade. The policy is year-three claims-made, not mature. The group shares an entity limit with a surgeon. No risk-management certificate is on file. The 2025 Miami-Dade internist manual is $59,736 before class mix, shared-limit structure, and missing credits. Endoscopy and hospitalist work can push class off the internist cell.

Same boards. Same years out. Different mix, venue, step year, FTE treatment, entity structure, and credits. That is malpractice pricing.

Putting the Nine Factors on Your File

List class, county, step year, limits, loss-run status, FTE, who is on the entity, deductible, and which credits you can prove. Compare quotes on those nine fields. A cheaper premium that drops prior acts, shares a limit you wanted separate, or codes you as 0.5 FTE you do not work is not a win.

You can often correct class, document hours, add a risk-management certificate, schedule an omitted NP, and ask for a claims-free credit without leaving the incumbent. You cannot talk a carrier out of a Miami-Dade cell or statewide filing. You can test whether another A-rated insurer weights the same nine factors differently.

How Quotes Get Misread

Comparing a year-two step rate to a mature competitor. Calling the class internal medicine when the CPT mix is not. Using a hospital-employed package as the independent-group yardstick. Ignoring whether defense sits inside limits. Assuming a clean year freezes a statewide filing. Those mistakes compare different products.

FAQ

What determines the cost of malpractice insurance?

Nine factors: specialty and procedures, venue, claims-made maturity, limits, loss history, FTE, entity and roster, deductible, and credits.

Why would two physicians in the same specialty get different quotes?

Different counties, procedure mix, step years, FTE, entity limits, deductibles, or credits. Same specialty is not the same class if one still delivers babies or scopes.

Does a clean claims record guarantee a low premium?

No. It helps loss history and credits. It does not override Miami-Dade versus Los Angeles, and it does not freeze a statewide filing.

How much of the premium is the entity versus the physician?

It depends on shared versus separate limits and roster size. The physician class-and-venue cell is usually the large number.

Can I change a factor without changing carriers?

Sometimes. Correcting class, documenting FTE, adding risk-management CME, and cleaning the roster can be done at renewal with the incumbent.

This article is for education only and is not legal, underwriting, or insurance advice.

Independent physician groups can have Sheltra map these nine factors across 5+ A-rated insurers in a 7-minute coverage review. Book a free coverage review at https://www.getsheltra.com/