AMA Says Health Plans Should Enforce Rules in New 10-Point 'Code of Conduct'

Cheryl Clark, May 25, 2010

The American Medical Association yesterday released its new Code of Conduct, a list of dos and don'ts that it says all health insurers should enforce.

The physician group says it hopes to publish a scorecard showing which plans play by these rules in a few years, in time for the launch of health exchanges enabled by health reform legislation.

As it released the new code, the AMA also sent letters to eight specific health insurance companies that it says have not had good track records in the past. They are Aetna, Cigna, Coventry Health Care, Health Net, Humana, Health Care Service Corp., UnitedHealth Group Inc and WellPoint.

"The decision to deal with these particular companies was not a random draw out of a hat," says AMA President J. James Rohack. "These companies were picked based on who has market dominance, and in particular, these companies were the ones that physicians had the most concerns over their past behaviors."

Rohack says that the code has been in the making for about 18 months, and "calls for transparency, so patients have the ability to choose insurers not only on the basis of price, but on the basis of the conduct toward their enrollees." A CD with resources will be distributed as well, to help physicians monitor each insurer's compliance with the code.

The AMA developed the code with support from 43 state medical associations and physician groups representing 19 types of specialized care, from the American Academy of Dermatology to the Renal Physicians Association.

In response, spokesman for America's Health Insurance Plans, Robert Zirkelbach, said, "Our top priority is ensuring patients have access to the safest and most effective healthcare treatments. All stakeholders need to work together to reduce gaps in care and the continued variation in practice patterns."

He added, "Health plans have pioneered innovative programs to reward quality, promote prevention and wellness, coordinate care for patients with chronic conditions, streamline administrative processes, and provide policyholders with greater peace of mind. We will continue to work with policymakers and other healthcare stakeholders to improve the quality, safety, and efficiency of our healthcare system."

The 10-point code includes 41 provisions, including:

1. Rescission and Cancellation. Health plans should not cancel plans "for innocent mistakes on applications, nor after significant delay," or for patients who become injured or severely ill after the policy is issued. Nor should plans pay bonuses or rewards for rescinding policies of sick consumers. Any cancellation must be subject to independent, outside review.

2. Premiums and Spending on Medical Services. Health plans must make profit and non-medical or administrative expenditures transparent to the public, and spend a "substantial bulk" of the premium dollar on direct medical care. They must price products fairly and give clear information on what's covered, copayments, coinsurance, and other information regarding the patient's financial responsibility.

3. Access. Provider directories must be accessible in paper and electronic format, including lists of which physicians, hospitals and other providers are accepting new patients, and which ones are restricted or out of network, or require other financial terms such as increased copayment.

4. Respectful Relations. Health plans must protect confidentiality of each enrollee's medical information, and "must cease such unfair practices with physicians as demanding unreasonable contract terms, improperly applying contractual discounts, unilaterally amending contracts or refusing to acknowledge contract terminations."

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