AMA resolution would hold managed care staff liable

Delegates say insurance company workers who interfere with claims payments should be punished.

By Robert Kazel, amednews staff. July 7, 2003.

Chicago -- Individual employees of managed care organizations, not just the health plans themselves, should be held liable if they obstruct claims payments to physicians, a new AMA policy suggests.

A resolution adopted in June by the Association's House of Delegates says the AMA will push for employees of managed care plans and insurance companies to be subject to "heavy penalties" if claims payments are not handled properly -- for example, if reimbursements are illegally denied or delayed. Previous AMA policy identified only the plans as targets for penalties.

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The policy was one of several actions by delegates that took a firm stance on payers, attempting to address some of the headaches doctors face in their dealings with plans.

"Bring it on," Thomas Whalen, MD, a pediatric surgeon and delegate from New Brunswick, N.J., said of holding insurance workers liable. "These [employees] just shield themselves under the corporate umbrella. The more we can do ... across the board, the better it would be."

Doctors often run into health plan employees suffering from "Friday afternoon clean-desk syndrome," said J. James Rohack, MD, a cardiologist in Temple, Texas, and an AMA board member. Claims appear to "magically disappear and are lost" in too many cases, he said.

But talking about holding insurance workers liable has a "punitive tenor" to it that overlooks the point that the great majority of patient claims are processed efficiently, said Susan Pisano, spokeswoman for the American Assn. of Health Plans.

To improve the speed of claims processing, she said, doctors should concentrate on working with their professional associations to learn ways to file claims as cleanly as possible.

"Health plans want to work constructively," she said. "I think they know it represents a competitive advantage, frankly. It's a good thing to pay on time."

Also at the Annual Meeting, delegates approved a resolution affirming that payment rates of private health plans should move to "decouple" their pricing from corresponding Medicare rates, so that compensation from insurers would not automatically decrease if Medicare payment levels do. Many private insurers tie their payment rates to Medicare's resource-based relative value scale, a tendency that has had a negative impact on physician revenues, said Richard S. Frankenstein, MD, a pulmonary disease specialist and alternate delegate from Garden Grove, Calif.

"There should never be a case where health plans are allowed to piggyback on Medicare reductions," Dr. Frankenstein said.

In other actions relating to managed care and access to treatment, the delegates also:

Directed the AMA's CPT coding staff to study new ways for doctors to report preventive services and evaluation and management services when performed during the same visit.
Agreed to support a requirement that health claims adopt a "full disclosure" policy with regard to how they treat doctors in PPO networks. Explanation of benefits statements should explain which PPO contract applies to each reimbursement rate; doctors should get their contracts to review at least annually, or on request; and no changes should be made in contracts without the physician's prior written authorization.
Declared their opposition, in the area of physician credentialing, to health plans' use of information about liability claims that are threatened, pending or closed.
Decided to create a new "user-friendly" Web site, accessible only to AMA members, that will supply doctors with information on current litigation, regulations and laws pertaining to HMOs. The site would bring together information now available on various parts of the AMA's present Web site.
Voted to support laws requiring pharmacies to list the full retail price of prescription drugs on receipts, so patients can understand what medications cost regardless of their insurance coverage.
Affirmed their intention to work with nursing organizations and other allied health associations to help address the shortage in nurses, technicians and other health professionals.