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Coding and Payment
Payment for Non Face-to-Face Physician Services
Payment, Care Management Function
Performance Measures Criteria
Physician Profiling, Guiding Principles
Tiered and Select Physician Networks
Physician Performance Reporting, Guiding Principles
The AAFP believes that any payment system must address the following principles:
- Quality care, access to care and positive health outcomes must be the primary goals of any payment system.
- The unique partnership embodied in the doctor/patient relationship must be preserved.
- A payment system must be based on continuing, comprehensive care rather than fragmented care and should encourage treatment on an ambulatory basis rather than in a costly institutional setting.
- There must be recognition of the value of prevention, early diagnosis and early treatment with appropriate incentives to the patient and to the physician to participate.
- Increased emphasis must be placed on payment for the cognitive portion of physician services, recognizing that this will likely result in lower payment for other services.
- 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.
- Certain factors (e.g., medical resources, locales, etc.) that diminish access to needed and quality medical care exist and may arise in the future. In these instances, national policies, such as a multiplier to the Resource-Based Relative Value Scale (RBRVS), that provide appropriate payment incentives may be given to physicians who will serve these underserved needs or areas.
- There must be substantial physician involvement in determining appropriate values to be assigned to payment for various physician services.
- Sufficient flexibility must be built into the system to recognize individual variation inherent in medical encounters, including the patient's health status or special circumstances, complications which may arise, severity of illness and other reasons.
- Individual physicians in independent practice must retain the right to set their own charges and the option to have those charges differ from the amounts scheduled for payment. In determining their charges, physicians' considerations should include, but not be limited to:
- the amount of skill and/or special training required;
- the amount of time spent providing the service;
- the risk involved in supplying the service;
- special economic considerations for the financially disadvantaged;
- supplies and equipment used;
- the use of ancillary personnel in providing the service; and
- costs of maintaining an appropriate facility for providing the service.
- Assurance of quality and appropriate utilization of services through peer review mechanisms shall remain the responsibility of the medical profession at the local level, with sufficient opportunity for involvement by all specialties.
- Any payment system must include provisions for annual reevaluation to keep the system current, so it reflects changing economic factors affecting the cost of delivering services.
- Any payment system which utilizes or contracts for case management services should pay appropriately for these services.
- Payment for services should be established according to an RBRVS which takes into account the unique practice expenses and professional liability costs of primary care physicians and uses a single conversion factor for all physician services.
- The value of family physicians' role in diagnosing, managing, and coordinating the delivery of mental health services should be recognized by adequate payment by all payors responsible for mental health coverage. The role and payment of family physicians in the delivery of mental health services should not be limited by plan design.
- Periodic preventive services should be paid by all public and private insurers when performed in the same anniversary month as they were last performed.
- Physicians should be paid for electronic communication, consultations, and care coordination services that they provide for the medical management of their established patients as a separate service unrelated to an evaluation and management (E/M). (see Payment for Non Face-to-Face Physician Services and Care Management).
(2001) (2009 COD)