Patient Support & Advocacy

Policies aim to ease patient burdens for out-of-network care

The AMA House of Delegates (HOD) adopted policy seeking to prevent disruptions in care after patients switch health plans while a course of treatment is in progress.

Delegates at the 2017 AMA Annual Meeting in Chicago recognized the need for patients who switch health plans while undergoing treatment for a serious condition such as cancer, or who are in their second or third trimesters of pregnancy, to have the option to  continue receiving care from physicians they know and trust.

The policy came out of a Council on Medical Service report, which underscored that new measures were needed to prevent disruptions in care for patients in active courses of treatment, especially for new enrollees in a health plan. The council stressed that patients who change health plans while in an active course of treatment “should also have the opportunity to receive continued transitional care from their treating out-of-network physicians and hospitals at in-network cost-sharing levels.”

Long-standing AMA policy already supports giving patients the opportunity for continued transitional care from physicians who leave their health plan networks or whose health plan contracts are terminated without cause.

“Moving forward, the AMA should continue to provide assistance upon request to state medical associations in support of state legislative and regulatory efforts ... to ensure continuity of care protections for patients in an active course of treatment—both for existing and new health plan enrollees,” the council wrote.

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Out-of-network payment and billing issues

In addition to the council report, there were four resolutions on access to out-of-network care. Among the resolutions was an effort by hospital-based physicians and several states medical societies to hold patients harmless from costs associated unanticipated out-of-network care and ensure incentives for insurers to contract with physicians through fair payments.   

Advocates for a change in AMA policy cited the need to address the causes of unanticipated out-of-network care as well, including inadequate networks and gaps in insurance coverage.

“We have a PR war like nothing we’ve seen before,” Rebecca Parker, MD, president of the American College of Emergency Physicians, said during reference-committee testimony.

The reference committee combined these resolutions into one measure which reaffirmed existing AMA policy and included new policies. As adopted by the HOD, these say that:

  • Patients must not be financially penalized for receiving unanticipated care from an out-of-network provider.
  • Insurers must be transparent and proactive in informing enrollees about all deductibles, co-payments and other out-of-pocket costs that enrollees may incur.
  • The AMA should develop model state legislation to address coverage and payment for out-of-network care.
  • Out of network coverage should be established using geographic data from a benchmarking database that is independently recognized, transparent, verifiable and maintained by a nonprofit organization that is not affiliated with an insurer, municipal cooperative health benefit plan or health management organization.

Read more news coverage from the 2017 AMA Annual Meeting.