Ama Policy

Code of Medical Ethics: 10.1.1 Ethical Obligations of Medical Directors

U.R. Criteria

Physicians’ core professional obligations include acting in and advocating for patients’ best interests. When they take on roles that require them to use their medical knowledge on behalf of third parties, physicians must uphold these core obligations.

When physicians accept the role of medical director and must make benefit coverage determinations on behalf of health plans or other third parties or determinations about individuals’ fitness to engage in an activity or need for medical care, they should:

(a) Use their professional expertise to help craft plan guidelines to ensure that all enrollees receive fair, equal consideration.

(b) Review plan policies and guidelines to ensure that decision-making mechanisms:

(i) are objective, flexible, and consistent;

(ii) rest on appropriate criteria for allocating medical resources in accordance with ethics guidance.

(c) Apply plan policies and guidelines evenhandedly to all patients.

(d) Encourage third-party payers to provide needed medical services to all plan enrollees and to promote access to services by the community at large.

(e) Put patient interests over personal interests (financial or other) created by the nonclinical role.

AMA Principles of Medical Ethics: I,III,VII

The Opinions in this chapter are offered as ethics guidance for physicians and are not intended to establish standards of clinical practice or rules of law.

Policy Timeline

Issued: 2016