Action taken to reduce claim denial, allow audit equity

AMA policies seek to give physicians an equal footing with insurance companies regarding payment.

By Victoria Stagg Elliott, AMNews staff. Jan. 5, 2004.

Honolulu -- When Gregory Cooper, MD, a family physician in Cynthiana, Ky., writes a prescription for an antidepressant, the patient's insurance company may deny reimbursement. Although treatment of many forms of depression is widely considered to be well within the purview of primary care physicians, the insurer may refuse to pay the claim because Dr. Cooper is not a psychiatrist.

"I'm trained to treat depression, and it's a very common diagnosis in my practice," said Dr. Cooper, an AMA delegate.

This situation, where payment is denied solely because of a physician's specialty, is what the AMA wants to work toward eliminating, according to policy approved at the Association's Interim Meeting in December 2003.

The policy calls for the AMA to support "appropriate action" at the state and federal levels to ban such denials, while also actively discouraging insurance companies from continuing this practice.

"There are many things that do not need specialty care," said John C. Nelson, MD, MPH, AMA president-elect and an obstetrician-gynecologist from Salt Lake City. "For example, if a person came to me with a scar on her abdomen from a previous surgery, I have the ability to revise that scar, particularly if I'm doing another procedure. If that scar were on a person's face, I'm not going to touch that because that's a very technical area that needs to be dealt with correctly. I know my limits."

Many specialists supported the policy because it goes beyond finances and restricts access to care, especially when the required specialist may not be accessible or be in short supply.