Ama Policy

Inappropriate Bundling of Medical Services by Third Party Payers D-70.983

Payment Edits, Prompt Payment Deadlines

Our AMA will: (1) continue to promote its Private Sector Advocacy activities and initiatives associated with the collection of information on third party payer modifier acceptance and inappropriate bundling practices;(2) use the data collected as part of its Private Sector Advocacy information clearinghouse to work, in a legally appropriate manner, with interested state medical associations and national medical specialty societies to identify and address inappropriate third party payer coding and reimbursement practices, including inappropriate bundling of services, rejection of CPT modifiers, and denial and delay of payment;

(3) continue to monitor the class action lawsuits of state medical associations, and provide supportive legal and technical resources, as appropriate;

(4) develop model state legislation to prohibit third party payers from bundling services inappropriately by encompassing individually coded services under other separately coded services unless specifically addressed in CPT guidelines, or unless a physician has been specifically advised of such bundling practices at the time of entering into a contractual agreement with the physician;

(5) urge state medical associations to advocate the introduction and enactment of AMA model state legislation on claims bundling by their state legislatures; and.

(6) highlight its Private Sector Advocacy document on bundling and downcoding, the related section of the AMA Model Managed Care Contract, and its advocacy initiatives on its web site and other communications measures to assure that physicians are aware of the AMA’s advocacy on this issue.

Policy Timeline

CMS Rep. 6, I-01Reaffirmed: CMS Rep. 7, A-11Reaffirmed: CMS Rep. 1, A-21