Delegates rally against unjust health plan conduct

The AMA targets code blending, economic profiling and other payer practices it says are unfair.

By Kevin B. O'Reilly, AMNews staff. Dec. 4, 2006.

Las Vegas -- The AMA House of Delegates inveighed against insurer practices it said hurt physicians and patients, such as the blending of evaluation and management payment codes, tiered physician networks, secondary PPO discount markets and economic profiling of doctors.

Unfair insurer practices are happening "across the board," said AMA Trustee Joseph P. Annis, MD. Carriers are "the middle man extracting billions out of the health care system -- money that should be going to take care of patients."

The AMA already has policy opposing insurers' manipulation of CPT coding, but that has not been enough to stop payers from unilaterally blending different coding levels to lower overall reimbursements to physicians. At their Interim Meeting last month, delegates directed the AMA to push for congressional action to make the practice illegal.

Delegates also adopted two resolutions targeting insurers' use of opaque economic data to grade physicians and shift patients toward doctors who provide services at discounted fees. The first, on tiered and narrow physician networks, says payers should "disclose, in plain language, the criteria by which the carrier creates a tiered, narrow or restricted network." Those networks should not be driven inappropriately by economic criteria or limit the number of preferred specialists available to patients in an area, the resolution said.

A second resolution, on economic profiling, said the AMA should oppose insurers' arbitrary use of efficiency measures and attempt to ensure that they adhere to the Association's principles and guidelines on pay-for-performance, adopted in June 2005. Delegates also directed the AMA to explore potential legal action to stop economic profiling.