Ama Policy

Fair Market Practices H-285.981

Credentialing-Due Process-Denial of Contract, Profiling, U.R. Criteria

Our AMA: continues to advocate for the enactment of state and federal laws and regulations that would provide for patient protection and physician fairness, including: (a) permitting physicians to negotiate individually and collectively with managed care organizations on the terms and conditions of physician participation in a managed care organization’s health benefits plans; (b) providing for formal input by practicing physicians in the development and refinement of the medical policies of a managed care organization, especially those policies related to physician credentialing, performance review, and utilization review; (c) requiring managed care organizations to disclose all participation requirements and selective contracting criteria to applying physicians; (d) requiring managed care organizations to provide due process to physicians in all adverse selective contracting decisions; and (e) providing enrollees and participating physicians with the opportunity to complete a “report card” at regular intervals for appropriate dissemination regarding the quality of service rendered by the managed care organization.


Policy Timeline

Sub. Res. 704, A-94 Res. 716, A-95 Reaffirmed by Rules & Credentials Cmt., A-96 Reaffirmed: Sub. Res. 718, 722, and Reaffirmation I-96 Reaffirmed by CMS Rep. 3, A-98 Reaffirmation A-06 Reaffirmation A-07 Modified: CMS Rep. 01, A-17