See also:
High Deductible Health Plans
Managed Care Reform
Patient-Centered Formularies
Coding and Payment
Third Party Payer Credentialing
Health Plans
Principles of Interaction Between Family Physicians and Health Plans
The Academy has developed this document as a statement of AAFP policy on family physician's 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 and 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 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 Practice Support Division at the Academy's headquarters.
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 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 Practice Support Division at the Academy's headquarters.
Health Plans Defined
For portions of this policy, the term “health plans” may extend beyond health insurers to include third-party administrators and repricers. A repricer is an entity that reviews procedures, diagnoses, fee schedules, and other data and determines the eligible amount billed for a given health care service or supply.
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 whom 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, health plans 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. In those health plans where primary care physician selection is required, and where physicians have responsibility and accept financial risk for identified patients, health plans should assist plan participants in selecting a primary care physician by providing them with timely and accurate information regarding individual physicians. Such information should not add significantly to physician administrative time or costs. Additionally, health plans should require participants to choose their primary care physician no later than 30 days after the policy's effective date. Participants should be provided with written or electronic identification of their chosen primary care physician or medical group and contracted hospital(s) no later than 30 days after the selection of a primary care physician.
5. Health plans should be required to disclose to plan enrollees upon request information regarding the aggregate number of medical review determinations that disagree with physician judgment or the percent of initial determinations reversed on appeal.
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 physicians 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.
10. In the marketing of managed care or health insurance plans, there must be a clear understanding of the contracts among physicians, other providers, payors and patients. Limitations on freedom of choice of physicians and/or hospitals, type and range of care to be provided, and information regarding enrollment and disenrollment procedures are issues that must be specifically and clearly addressed in marketing and promotion materials.
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 whom 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, health plans 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. In those health plans where primary care physician selection is required, and where physicians have responsibility and accept financial risk for identified patients, health plans should assist plan participants in selecting a primary care physician by providing them with timely and accurate information regarding individual physicians. Such information should not add significantly to physician administrative time or costs. Additionally, health plans should require participants to choose their primary care physician no later than 30 days after the policy's effective date. Participants should be provided with written or electronic identification of their chosen primary care physician or medical group and contracted hospital(s) no later than 30 days after the selection of a primary care physician.
5. Health plans should be required to disclose to plan enrollees upon request information regarding the aggregate number of medical review determinations that disagree with physician judgment or the percent of initial determinations reversed on appeal.
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 physicians 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.
10. In the marketing of managed care or health insurance plans, there must be a clear understanding of the contracts among physicians, other providers, payors and patients. Limitations on freedom of choice of physicians and/or hospitals, type and range of care to be provided, and information regarding enrollment and disenrollment procedures are issues that must be specifically and clearly addressed in marketing and promotion materials.
Health Plan Infrastructure and Process
11. 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.
12. 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 its enrollees the opportunity to select a primary care physician (MD or DO) as their personal physician to provide continuing medical management and care coordination.
13. Health plans must explicitly include family physicians in any reference to access to "women's health services and services for children and the aged."
14. Health plans should have sufficient financial reserves and infrastructure to ensure proper payment for covered services within 30 days (or less if set by state statutes) of submission of a "clean" claim. Payments made after the 30-day (or less) limit, unless otherwise set forth in the state statutes, should include an interest penalty based on a commercially reasonable interest rate.
15. Health plans should establish physician advisory group through which physicians enrolled with the plan can provide input into the plan's policies affecting the quality of patient care.
16. 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.
17. 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.
18. 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. Physicians should have access to the clinical guidelines for all health plans in which they participate via websites and/or written materials. All clinical guidelines should be based on the best available evidence.
19. Health plans should respond to requests for prior authorization of a non-emergency service, upon receipt of complete information, within two business days.
20. Health plans may impose an additional, actuarially justified premium and higher patient cost-sharing requirement for enrollees choosing products with "out-of-network" care options.
12. 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 its enrollees the opportunity to select a primary care physician (MD or DO) as their personal physician to provide continuing medical management and care coordination.
13. Health plans must explicitly include family physicians in any reference to access to "women's health services and services for children and the aged."
14. Health plans should have sufficient financial reserves and infrastructure to ensure proper payment for covered services within 30 days (or less if set by state statutes) of submission of a "clean" claim. Payments made after the 30-day (or less) limit, unless otherwise set forth in the state statutes, should include an interest penalty based on a commercially reasonable interest rate.
15. Health plans should establish physician advisory group through which physicians enrolled with the plan can provide input into the plan's policies affecting the quality of patient care.
16. 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.
17. 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.
18. 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. Physicians should have access to the clinical guidelines for all health plans in which they participate via websites and/or written materials. All clinical guidelines should be based on the best available evidence.
19. Health plans should respond to requests for prior authorization of a non-emergency service, upon receipt of complete information, within two business days.
20. Health plans may impose an additional, actuarially justified premium and higher patient cost-sharing requirement for enrollees choosing products with "out-of-network" care options.
Health Plan Anti-Discrimination
21. Health care insurance plans should not discriminate against individuals with expensive, long-term or chronic medical conditions.
22. 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.
23. Employers and health plans should not discriminate by gender in the provision of health are benefits including a) prescription contraceptive drugs and devices and b) elective sterilization procedures. These benefits should be covered under the same terms and conditions as other prescription drugs and devices and elective surgeries.
24. 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.
22. 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.
23. Employers and health plans should not discriminate by gender in the provision of health are benefits including a) prescription contraceptive drugs and devices and b) elective sterilization procedures. These benefits should be covered under the same terms and conditions as other prescription drugs and devices and elective surgeries.
24. 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
25. 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 their care. Family physicians are uniquely qualified to serve in this role.
26. Health plans should provide "out-of-network" services at in-network benefit levels to enrollees for those covered services not available through network providers.
27. Although the AAFP recognizes that non-physician personnel are valuable resources and well-equipped to assist in providing many aspects of patient care, the AAFP continues to support a patient's right to choose a physician.
28. Health plans and physician practices which utilize non-physician care providers should provide information to members/patients regarding the possibility of being seen by a non-physician provider. Such information should be stated in clear terms in plan/practice advertisements and communications, the information should be made known to the patient at the time their appointment is made, and should be clearly stated by the non-physician provider at the time the patient is seen.
29. Health plans should cover emergency medical services as defined by a "prudent lay person" 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 lay person" definition.
30. 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 or medical necessity decisions made by the plan.
26. Health plans should provide "out-of-network" services at in-network benefit levels to enrollees for those covered services not available through network providers.
27. Although the AAFP recognizes that non-physician personnel are valuable resources and well-equipped to assist in providing many aspects of patient care, the AAFP continues to support a patient's right to choose a physician.
28. Health plans and physician practices which utilize non-physician care providers should provide information to members/patients regarding the possibility of being seen by a non-physician provider. Such information should be stated in clear terms in plan/practice advertisements and communications, the information should be made known to the patient at the time their appointment is made, and should be clearly stated by the non-physician provider at the time the patient is seen.
29. Health plans should cover emergency medical services as defined by a "prudent lay person" 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 lay person" definition.
30. 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 or medical necessity decisions made by the plan.
Health Plan/Physician Contracting
31. 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.
32. Physicians should not enter into contractual arrangements with health plans which compromise the physician's ability to make appropriate clinical decisions in their patients' best interests.
33. Any contract that a health plan offers to physicians or physician organizations must specify the insurance products covered by the contract. No contract should obligate those physicians or physician organizations who sign the contract to participate in insurance products not specifically identified by the contract. Physicians should have adequate time to evaluate a new product prior to being added to any new provider panel.
34. Family physicians should be permitted to contract, provide and be paid for services within the full scope of their training and experience.
35. Physicians should be paid to perform services, both cognitive and procedural, for which they have documented training and/or experience, demonstrated abilities and current competence. (See Academy policy on Physician Payment.)
36. Health plans, including ERISA plans, should not tie a physician's membership in one managed care panel to that physician's participation in any other managed care panel.
37. In those health plans where primary care physician selection is required and where physicians have responsibility and accept financial risk for identified patients, health plans should notify primary care physicians selected by a health plan participant no later than 30 days after the selection of a primary care physician. Additionally, health plans should pay any contractual monthly capitation fee to that physician from the effective date of the participant's coverage.
38. Most health plans have a requirement for the timely submission of claims. It is appropriate, therefore, that there be a defined period within which plans can retract paid claims (claims for noncovered benefit or ineligible patient) and/or request repayment of claims overpayments. Retraction of paid claims and recovery of overpayments should adhere to the following principles:
32. Physicians should not enter into contractual arrangements with health plans which compromise the physician's ability to make appropriate clinical decisions in their patients' best interests.
33. Any contract that a health plan offers to physicians or physician organizations must specify the insurance products covered by the contract. No contract should obligate those physicians or physician organizations who sign the contract to participate in insurance products not specifically identified by the contract. Physicians should have adequate time to evaluate a new product prior to being added to any new provider panel.
34. Family physicians should be permitted to contract, provide and be paid for services within the full scope of their training and experience.
35. Physicians should be paid to perform services, both cognitive and procedural, for which they have documented training and/or experience, demonstrated abilities and current competence. (See Academy policy on Physician Payment.)
36. Health plans, including ERISA plans, should not tie a physician's membership in one managed care panel to that physician's participation in any other managed care panel.
37. In those health plans where primary care physician selection is required and where physicians have responsibility and accept financial risk for identified patients, health plans should notify primary care physicians selected by a health plan participant no later than 30 days after the selection of a primary care physician. Additionally, health plans should pay any contractual monthly capitation fee to that physician from the effective date of the participant's coverage.
38. Most health plans have a requirement for the timely submission of claims. It is appropriate, therefore, that there be a defined period within which plans can retract paid claims (claims for noncovered benefit or ineligible patient) and/or request repayment of claims overpayments. Retraction of paid claims and recovery of overpayments should adhere to the following principles:
- The time limit for retraction of paid claims and recovery of overpayments should be the same as the time limit required for claim submission by the physician.
- Physicians should either pay or contest the retraction of paid claims and/or overpayment within 60 days of being notified by the plan.
- In those instances where the retraction of paid claims or overpayment is sufficiently large that returning it in full would financially damage the practice there should be a provision for incremental repayment.
- In the situation in which an identified retraction of paid claims or overpayment resulted from documented advice or guidance that the physician received from the plan, a return of the overpayment should not be required of the physician and the plan should be liable for the amount in question.
39. AAFP believes that when evaluating a health plan's contract, consideration should be given to additional fees or additional costs required to participate in the plan (participation fees, utilization programs or quality improvement initiatives). It may be appropriate to refuse to accept these additional fees or decline participation in the plan if these additional costs are unacceptable.
(1999) (April Board 2009-Revised)
