Include FPs in Utilization Review Process, Says AAFP

March 23, 2010 04:15 pm News Staff

The Academy recently contacted representatives from two Washington D.C.-based organizations to ensure that family physicians continue to be included in utilization review activities.

In letters sent on March 19 to the Utilization Review Accreditation Committee, or URAC, and the National Committee for Quality Assurance, or NCQA, -- organizations whose work includes the accreditation of health plans -- the AAFP specifically asked the groups to ensure that FPs continue to be included in utilization review activities "when providing utilization management determinations for health plans."

Health plans routinely evaluate their physician panels to determine if physicians are using their services appropriately. The URAC and the NCQA are responsible for setting guidelines for health insurance companies to help ensure the authenticity of their utilization review programs.

The Academy's request came at the direction of the AAFP's Congress of Delegates, and both URAC and the NCQA currently require that family physicians participate in the utilization review process.

However, letters to both URAC and the NCQA from AAFP Board Chair Ted Epperly, M.D., of Boise, Idaho, emphasized the importance of continuing to include family physicians in utilization review.

"Our understanding is that URAC utilization management program accreditation for health plans includes a national standard which in part states that the physicians reviewing patient treatment plans must be 'in the same profession and in a similar specialty as typically manages the medical condition, procedure, or treatment as mutually deemed appropriate,'" says Epperly in a letter to URAC.

A letter to the NCQA held a similar message: "Our understanding is that NCQA employs and encourages family physicians' participation in its utilization management program accreditation for health plans."

The letters were sent as reminders to both organizations that as the health care system undergoes change and insurers work to improve efficiencies, FPs must be utilized as reviewers when appropriate because they represent a cross section of health care professionals and provide a broad scope of services to patients.

As evidence, Epperly pointed out that, "Family medicine residents are trained, educated and competent to provide for patients across the full spectrum of care." He said residents care for patients of all ages, including children, through a longitudinal continuity clinic during residency as well as months of focused time on inpatient and outpatient services.

"Family physicians are well-dispersed geographically in relation to the general population, and more than 5 million children and adolescents rely on family doctors for their care (because) they live in counties with no pediatrician," said Epperly.


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