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

Cheryl Clark, for HealthLeaders Media , May 25, 2010

5. Medical Necessity. Health plans must cover all emergency screening and treatment services "without regard to prior authorization or the treating physician's or other healthcare provider's contractual relationship with the payer." Also, they may not use financial incentives that discourage doctors from recommending, prescribing, or rendering medically necessary care.

6. Benefit Management. Health plans will not change formularies or other benefits during the plan coverage year, and may not force physicians to change medications or treatments for patients who have been stabilized on a particular course of care, nor charge patients more for changes. "Financial incentives must not corrupt benefit decisions."

7. Administrative Simplification. Health plans must eliminate complexity and confusion from processes and communications. Also health insurers should minimize and streamline requirements they impose on patients and providers to provide information and approvals. "Health insurers must maintain sufficient staff and infrastructure to respond promptly."

8. Physician Profiling. Systems must be focused on improving quality, not on reducing cost, must use good relevant data and produce accurate, statistically valid results reflecting matters within the doctor's control, and must be appropriately risk-adjusted to account for patient variation.

9. Corporate Integrity. Policies prohibiting conflicts of interest, retaliation against whistleblowers and sharp business practices must be aggressively enforced.

10. Claims Processing. Health plans must pay claims accurately and timely and provide clear, comprehensive explanations of any denial or reduction of payment. Patients and physicians "must have a fair, fast, and cost-effective right to appeal any contested claim."

Several health plans sent statements in response to the AMA's release of its Code of Conduct.

Ross Blackstone, spokesman for HCSC, said, "We are aware of the contents and we do adhere to the code of conduct principles as outlined by the AMA. In fact, we have been doing so for quite some time."

Patrick Johnston, president of the California Association of Health Plans provided this response: "Partnerships between doctors and health plans in California are a national model in effectively and efficiently delivery care.

"Couple these effective partnerships with change required in federal health reform and the high standards California law establishes for health plans and the physicians with whom we work and we have addressed many concerns. Additionally, health plans established programs that streamline the administrative work of health care, help manage chronic conditions, and provide incentives for quality care."

Other health plans that received letters did not respond to requests for comment.

Rohack says that the AMA and the other physician groups want patients and providers to know up front which health plans are playing by these rules.

"It is frustrating to have to go through the court system to finally rectify wrongs, like the experience we had with the lawsuits that were filed against health insurers in 2000 for abuse of practices," he says. "They were finally settled six or seven years later."

Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.

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