Ama Policy

Approaches to Increase Payer Accountability H-320.968

State Medical Necessity Decisions-Deadlines, U.R. Criteria

Our AMA supports the development of legislative initiatives to assure that payers provide their insureds with information enabling them to make informed decisions about choice of plan, and to assure that payers take responsibility when patients are harmed due to the administrative requirements of the plan. Such initiatives should provide for disclosure requirements, the conduct of review, and payer accountability.

(1) Disclosure Requirements. Our AMA supports the development of model draft state and federal legislation to require disclosure in a clear and concise standard format by health benefit plans to prospective enrollees of information on

(a) coverage provisions, benefits, and exclusions;

(b) prior authorization or other review requirements, including claims review, which may affect the provision or coverage of services;

(c) plan financial arrangements or contractual provisions that would limit the services offered, restrict referral or treatment options, or negatively affect the physician’s fiduciary responsibility to his or her patient;

(d) medical expense ratios; and

(e) cost of health insurance policy premiums. (Ref. Cmt. G, Rec. 2, A-96; Reaffirmation A-97)


(2) Conduct of Review. Our AMA supports the development of additional draft state and federal legislation to:

(a) require private review entities and payers to disclose to physicians on request the screening criteria, weighting elements and computer algorithms utilized in the review process, and how they were developed;

(b) require that any physician who recommends a denial as to the medical necessity of services on behalf of a review entity be of the same specialty as the practitioner who provided the services under review;

(c) Require every organization that reviews or contracts for review of the medical necessity of services to establish a procedure whereby a physician claimant has an opportunity to appeal a claim denied for lack of medical necessity to a medical consultant or peer review group which is independent of the organization conducting or contracting for the initial review;

(d) require that any physician who makes judgments or recommendations regarding the necessity or appropriateness of services or site of service be licensed to practice medicine in the same jurisdiction as the practitioner who is proposing the service or whose services are being reviewed;

(e) require that review entities respond within 48 hours to patient or physician requests for prior authorization, and that they have personnel available by telephone the same business day who are qualified to respond to other concerns or questions regarding medical necessity of services, including determinations about the certification of continued length of stay;

(f) require that any payer instituting prior authorization requirements as a condition for plan coverage provide enrollees subject to such requirements with consent forms for release of medical information for utilization review purposes, to be executed by the enrollee at the time services requiring such prior authorization are recommended or proposed by the physician; and

(g) require that payers compensate physicians for those efforts involved in complying with utilization review requirements that are more costly, complex and time consuming than the completion of standard health insurance claim forms. Compensation should be provided in situations such as obtaining preadmission certification, second opinions on elective surgery, and certification for extended length of stay.

(3) Accountability. Our AMA believes that draft federal and state legislation should also be developed to impose similar liability on health benefit plans for any harm to enrollees resulting from failure to disclose prior to enrollment the information on plan provisions and operation specified under Section 1 (a)-(d) above.

Policy Timeline

BOT Rep. M, I-90 Reaffirmed by Res. 716, A-95 Reaffirmed by CMS Rep. 4, A-95 Reaffirmation I-96 Reaffirmed: Rules and Cred. Cmt., I-97 Reaffirmed: CMS Rep. 13 , I-98 Reaffirmation I-98 Reaffirmation A-99 Reaffirmation I-99 Reaffirmation A-00 Reaffirmed in lieu of Res. 839, I-08 Reaffirmation A-09 Reaffirmed: Sub. Res. 728, A-10 Modified: CMS Rep. 4, I-10 Reaffirmation A-11 Reaffirmed in lieu of Res. 108, A-12 Reaffirmed: Res. 709, A-12 Reaffirmed: CMS Rep. 07, A-16 Reaffirmed in lieu of: Res. 242, A-17 Reaffirmed in lieu of: Res. 106, A-17 Reaffirmation: A-17 Reaffirmation: I-17 Reaffirmation: A-18 Reaffirmation: A-19 Reaffirmed: Res. 206, I-20 Reaffirmation: A-22