Our AMA adopts the following principles for the development and application of utilization management guidelines:

(1) The criteria or guidelines used for utilization management shall be based upon sound clinical evidence and consider, among other factors, the safety and effectiveness of diagnosis or treatment, and must be age appropriate.

(2) These utilization management guidelines and the criteria for their application shall be developed with the participation of practicing physicians.

(3) Appropriate data, clinical evidence, and review criteria shall be available on request.

(4) When used by health plans or health care organizations, such criteria must allow variation and take into account individual patient differences and the resources available in the particular health care system or setting to provide recommended care. The guidelines should also include a statement of their limitations and restrictions.

(5) Patients and physicians shall be able to appeal decisions based on the application of utilization management guidelines.

(6) The competence of non-physician reviewers and the availability of same-specialty peer review must be delineated and assured.

(7) Maintaining the best interests of the patient uppermost, the final decision to discharge a patient, or any other patient management decision, remains the prerogative of the physician.

Policy Timeline

BOT Rep. 6, A-99Reaffirmed: Res. 820, A-00Reaffirmed: CSAPH Rep. 1, A-10Reaffirmed: Res. 708, A-16Reaffirmed: CMS Rep. 08, A-17Reaffirmed: CMS Rep. 4, A-21