Lab test reports, contracts among key managed care issues

The AMA House of Delegates addresses ways physicians can provide good patient care under the current system -- while working to improve it.

By Julie A. Jacob, amednews staff. July 3, 2000.

Chicago -- While no one issue dominated discussion, the variety of managed-care related resolutions at the AMA's Annual Meeting in June was a clear indication that physicians are still very much concerned about their ability to provide good patient care and receive fair and timely payments in a managed care system.

Among the issues: laboratory reporting of unordered test results; increasing hospital-based physician input into hospital managed care contracts; and using the Association as a resource for state societies interested in filing class-action suits against managed care companies.

The issue generating the liveliest discussion among delegates was the Council on Medical Service's recommendation to require laboratories to routinely supply written reports of all abnormal or critical lab results, even if the physician did not order the test.

Physicians who favored the recommendation said that it is simply good medicine for laboratories to provide physicians with all abnormal test results, whether the tests were specifically ordered or not.

"Is it good medicine? Good medicine requires reporting laboratory results," said Carol Rose, MD, from Pennsylvania, an alternate delegate for the American Society of Anesthesiologists.

However, pathologists sharply opposed the recommendation, citing their concerns about laboratories violating CLIA regulations and being subject to fraud and abuse charges if they are compelled to give physicians written results of unordered tests.

"If we follow the AMA's recommendation, it would violate CLIA regulations stating that we can only provide results that were ordered," said Randy Eckert, MD, from Austin, Texas, representing the College of American Pathologists.

He added that laboratories nowadays do only tests that are ordered, instead of a full battery of tests. In the rare cases when the wrong test is ordered, laboratories will first call the physician and ask for written approval to release those results in order to comply with CLIA regulations. Dr. Eckert said that the College of American Pathologists will ask the AMA's legal department for a written analysis on the legality of laboratory compliance with the recommendation.

The AMA house also approved the Council on Medical Service's recommendation that hospital-based physicians should have the right to negotiate and review relevant portions of hospital contracts with managed care companies.

The approved resolution also called for physicians to receive advance notice of a hospital's intention to sign a capitated contract involving their specialty and to have the right to decline to participate in hospital managed care contracts that pose an unacceptable professional liability risk to physicians.

James Hayes, MD, a Dallas trauma surgeon and delegate representing the American College of Emergency Physicians, said the delegation was glad that the AMA had approved the CMS's recommendations. He said he hoped it would encourage hospitals to give physicians more say into managed care contracts that hospitals enter into with insurers.

The house also recommended that the Litigation Center of the AMA and the State Medical Societies serve as a resource for medical societies that are planning to file class-action lawsuits against managed care companies.

In other managed-care related business, the house:

Directed the AMA, through its participation in the National Uniform Claim Committee, to work with insurers to determine why claims are rejected and develop ways to improve the speed and efficiency of electronic claims approval.
Directed the Association to urge physicians to review carefully their managed care contracts to make sure they will receive reimbursement for diagnostic and therapeutic procedures performed in the office for which they have the appropriate training and experience.
Directed the AMA, in response to delegate concerns over the National Quality Forum becoming too closely linked with the federal Health Care Financing Administration, to take action to ensure that HCFA does not use the National Technology Transfer and Advancement Act to give the quality forum the power to set national health care standards.
Reaffirmed that board certification should not be a prerequisite for participation in a Medicaid HMO.
Directed the AMA to investigate and report back to the house on the advantages and disadvantages of the current peer review system and to develop model contract language to protect the right of physicians during peer review and credentialing.