Ama Policy

Physicians’ Experiences with Retrospective Denial of Payment and Down-Coding by Managed Care Plans D-320.995

Retroactive Denial

(1) Our AMA will re-distribute its model legislation that would prevent the retrospective denial of payment for any claim for services for which a physician had previously obtained authorization.

(2) Our AMA will work with private sector accreditation organizations to ensure that their health plan and utilization management accreditation standards adequately address fair and appropriate mechanisms for retrospective review.

(3) AMA’s Private Sector Advocacy unit will work with state medical associations, county medical societies, and national medical specialty societies to (a) develop a survey instrument for use by the Federation to gather information from physicians who experience retrospectively denied and/or down-coded claims, (b) seek information on a regular basis from those associations that collect such information, and (c) respond with appropriate legislation, advocacy, and communication initiatives.

Policy Timeline

CMS Rep. 5, I-00 Reaffirmed: CMS Rep. 6, A-10 Reaffirmed: Sub. Res. 728, A-10 Reaffirmation: A-18 Reaffirmation: A-22