Feb 1999 Table of Contents

Ground Rules for Dealing With Health Care Plans

A new AAFP document maps out the high ground for family physicians' relationships with managed care organizations.

Fam Pract Manag. 1999 Feb;6(2):33-35.

Five years ago, when managed care plans were marching onto the health care scene, no one was sure what the relationship between physicians and these new payers should look like. All anyone knew was the relationship wasn't easy. “Physicians were concerned about managed care companies treating them fairly,” says Bruce Bagley, MD, president-elect of the AAFP. “They were also concerned that managed care companies would prevent them from treating their patients properly.”

KEY POINTS:

  • The Academy has developed a set of principles to guide the interaction between physicians and health care plans.

  • Doctors can use the principles to evaluate their contractual relationships with plans and articulate their expectations about a positive working relationship.

It was a new relationship, and in many ways, time hasn't made the relationship any clearer. Even today, managed care companies and other third-party payers take many varied approaches in their contractual relationships with family physicians, “some far better than others,” says Berdi Safford, MD, medical director for a 42-family-physician group in northwest Washington and the recently elected chair of the AAFP's Commission on Health Care Services.

With these concerns before them, commission members began to craft a document that would “articulate what the basic ground rules should be for proper interaction between physicians and health plans,” says Bagley, who was chair of the commission when the document was drafted. Safford adds, “We were not in a position to evaluate each contract or to endorse an individual plan; therefore, we approached the problem with a set of general principles that our members could use themselves in the evaluation of health plan contracts.” In 1998 the commission finished its work on the document, and by September the “Principles of Interaction Between Family Physicians and Health Plans” was approved by the Congress of Delegates.

The principles, below, are intended to help family physicians evaluate their contractual relationships with health plans, articulate their expectations for proper behavior and educate colleagues and staff. “They can serve as a statement of the high ground that we should expect in our relationships with health plans,” says Safford.

Principles of Interaction Between Family Physicians and Health Plans

The Academy has developed this document as a statement of AAFP policy on family physicians' interaction with health care plans. Its intended use is to assist individual or groups of family physicians, constituent chapters and others in their efforts to work with managed care organizations and other health plans to provide high-quality, cost-effective health care to enrolled populations. The principles are meant to build bridges, not to erect barriers between family physicians and health plans.

As with any contract, physicians should fully understand the terms and conditions of any contractual relationship with a health plan prior to entering into an agreement (e.g., “without cause” provisions, “restrictive covenants,” “hold harmless” clauses). As such, the AAFP strongly encourages family physicians to seek individual legal counsel when considering physician contracts.

By necessity, this is a “living document” to which additions and modifications are routinely made by the AAFP Board as the health care market evolves and creates new challenges and opportunities. Suggestions concerning managed care, or other health care delivery and financing issues requiring the Academy's attention, should be directed to the attention of the Socioeconomics Division at the Academy's headquarters.

Health Plan Disclosure

  1. Health plans should provide sufficient information, in a manner appropriate to the population being served, about plan terms and conditions to allow prospective enrollees and patients to make informed enrollment decisions.

  2. Physicians must be able to discuss any information, clinical or financial, necessary for their patients to make informed decisions regarding their medical care. Physicians should avoid making disparaging remarks to patients about health plans with which they have contractual relationships. Health plans should avoid making disparaging remarks to members about physicians with whom they have contractual relationships.

  3. Upon patient request, a health plan should disclose to its enrollees information on the methodology it uses (including incentives and bonuses) to compensate its contracted physicians. Health plans should not be required to divulge information concerning payment formulae and/or exact payment amounts.

  4. Health plans should provide to plan participants meaningful information regarding individual physicians without, however, adding significantly to physician administrative time or costs.

  5. Health plans should not be required to disclose to plan enrollees information regarding utilization review determinations that disagree with physician judgment or the percent of initial determinations reversed on appeal. Health plan internal peer-review processes, other mandated quality assurance activities and the legal system are sufficient to protect patients.

  6. Health plans should provide to employers, enrollees and participating physicians the criteria and process used for determining when new technologies and procedures become a covered benefit and should be explicit in describing those services it will not currently cover because they are deemed to be “experimental.”

  7. Health plans should disclose contracting criteria to network physicians. Physicians, however, should recognize that some criteria utilized in determining physician selection, retention and disenrollment are based upon economic business decisions.

  8. Health plans should periodically provide each physician with data to evaluate his or her performance relative to stated plan performance criteria, and in relation to a comparable group of plan physicians, which are age, sex and severity adjusted.

  9. Physician profiling should be adjusted to recognize case mix, severity of illness, age of patient and other features of a physician's practice that may account for higher than, or lower than, expected costs.

Health Plan Infrastructure and Process

  1. Health plans should demonstrate that they can provide access to physicians and other providers so that all covered medical services are delivered in a clinically appropriate time frame.

  2. Health plans should assure that a physician is available 24 hours per day to provide diagnostic and treatment services to plan enrollees. All medical care received by a health plan enrollee should be provided under the medical management of a physician. Health plans should provide each of their enrollees the opportunity to select a primary care physician (MD or DO) as his or her personal physician to provide continuing medical management and care coordination.

  3. Health plans must explicitly include family physicians in any reference to access to “women's health services.”

  4. Health plans should have sufficient financial reserves and infrastructure to ensure proper and timely payment for covered services.

  5. Health plans should establish physician advisory groups through which physicians enrolled with the plan can provide input into the plan's policies affecting the quality of patient care.

  6. Health plans should develop quality criteria for physician credentialing to use in lieu of hospital admitting privileges for those physicians who no longer have an inpatient practice and have made alternative arrangements to admit their patients to health plan participating hospitals.

  7. Physicians involuntarily disenrolled from a health plan should be provided with the reason, the right to appeal the disenrollment decision and sufficient notice of disenrollment to allow the orderly transfer of patient care responsibilities.

  8. Health plan utilization review medical directors should make coverage decisions based on clinically sound guidelines. However, participating physicians should have the right to appeal adverse coverage decisions, and health plans should have in place systems to review and adjudicate physician appeals.

  9. Health plans should respond to requests for prior authorization of nonemergency services, upon receipt of complete information, within two business days.

  10. Health plans may impose additional, actuarially justified premiums and higher patient cost-sharing requirements for enrollees choosing products with “out-of-network care” options.

Health Plan Anti-Discrimination

  1. Health care insurance plans should not discriminate against individuals with expensive, long-term or chronic medical conditions.

  2. Health plans should not discriminate against members of high-risk, vulnerable or other similar patient populations by excluding physicians with practices containing substantial numbers of such patients.

  3. Health plans should not utilize any criterion that excludes a physician based on race, color, religion, gender, sexual orientation, ethnic affiliation, national origin or any other factor prohibited by law.

Patient Rights

  1. Patients should be free to make personal decisions concerning their selection of health care professionals, including their personal physician. Patient preferences and marketplace forces should determine patient access to needed health care services. The Academy believes that it is in the patient's best interest to have an appropriately trained personal physician responsible for overall coordination of his or her care. Family physicians are uniquely qualified to serve in this role.

  2. Health plans should provide out-of-network services at in-network benefit levels to enrollees for those covered services not available through network providers.

  3. Health plans and physician practices that utilize nonphysician care providers should provide information to members/patients regarding the possibility of being seen by a nonphysician provider. Such information should be stated in clear terms in plan/practice advertisements and communications, should be made known to patients at the time their appointments are made, and should be clearly stated by the nonphysician provider at the time the patient is seen.

  4. Health plans should cover emergency medical services as defined by a “prudent layperson” with an average knowledge of medicine. Additionally, health plans should cover out-of-area and out-of-network emergency medical services, at in-network benefit levels, using the same “prudent layperson” definition.

  5. Health plans should make available an external appeals process to enrollees, and physicians on behalf of enrollees, who have exhausted internal appeals processes regarding adverse-coverage/medical-necessity decisions made by the plan.

Health Plan/Physician Contracting

  1. The health plan and the physician should have equal opportunities to “terminate without cause” if such a clause is to be included in a contract between the parties.

  2. Physicians should not enter into contractual arrangements with health plans that compromise the physician's ability to make appropriate clinical decisions in patients' best interests.

October 1998, AAFP Reprint No. 203 - Order No. 784

Brandi White is a senior associate editor of Family Practice Management.

 

Copyright © 1999 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact fpmserv@aafp.org for copyright questions and/or permission requests.

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