Protocol for Handling Medical Specialty Specific Limitations

Medical Specialty Specific Issues
For Family Physicians Who Are Encountering Medical Specialty Specific Limitations
The American Academy of Family Physicians (AAFP) stands unequivocally in support of the concept that all physicians should be able to practice medicine in accordance with their individual qualifications, i.e., documented training and/or experience, demonstrated abilities, and current competence.

Is your issue with privileges at a facility (hospital, ambulatory care, etc.)? If “yes,” please visit the AAFP resources on Family Practice Privileges & Procedures. If “no” and your issue involves a non-facility entity (e.g. payer, pharmacy benefits manager, medical supply company, etc.) that is limiting your ability to practice the full scope of services for which you are qualified, please see the suggested protocol listed below that should prove helpful.

1. Do your homework
Collect information and get a full understanding of the basis the third party is using to limit your scope of services for which you are qualified. This would include, but not be limited to, a copy of the credentialing/re-credentialing process, contract term(s), evidence-based guidelines, Medicare National/Local Coverage Determinations, etc.

Some examples of private payers, pharmacy benefits managers, and radiology benefits managers limiting scope of services based on the Family Medicine specialty include: applying different rules (e.g. require prior authorization, sub-specialist referral necessary, etc.) for family physicians versus sub-specialists; disallowing family physicians from ordering certain prescription drugs; and not paying family physicians for certain health services (e.g. behavioral health, procedures, etc.).

2. Document Adequate Training and Experience
Review your credentials. You must show that your training and experience qualify you for the scope of services you are providing patients.

3. Assemble All Pertinent Documentation
Make sure that the documentation of your training, experience and current competence is well organized. Collect letters of recommendation from past instructors, preceptors, those who have monitored your clinical work as well as colleagues who have worked with you throughout the years. Assemble case reports including data about the number and types of cases, treatment outcomes, etc. Also, assemble documentation records maintained during your Family Medicine residency.

Your complete documentation, case reports, and letters of recommendation should be organized and readily available upon request. Save a copy of each document you submit to the third party in the event that the original documents are lost or misplaced. Further, it is advisable to maintain ongoing documentation of your clinical experiences.

4. Make Your Case
Before taking any action, fully understand the third party’s appeals process, including any time restrictions. Correspond in writing for documentation purposes and be sure to keep written notes on any conversations related to your case.

5. Insist on a Written Explanation
Be sure that the third party provides a written explanation of the basis for its decision that explicitly states the reason(s) why your scope of services has been limited or plan participation terminated.

6. Identify the "Real" Issue
Some questions to consider in uncovering the third party’s “real” issue are:

7. Seek Local Support
Since health care delivery is local, it is advisable to notify your AAFP Constituent/State Chapter, which may know of other members in a similar situation and/or have contacts at the third party that could be influential or provide further intelligence on how best to deal with your issue. Moreover, some chapters may have a committee that deals with such scope of services problems and may suggest other actions you could take, or perhaps write a letter of support on your behalf. It is a good idea to share your issue in writing with the constituent chapter, and include all pertinent data. Click here to find your chapter.

Your relationships with other family physicians, including sub-specialists, may be helpful in influencing the third party to change its decision.

8. Consider Legal Action.
Before taking legal action, you should request an opinion letter from your attorney that addresses the merits of your case. The opinion letter should include (i) the basis for taking legal action, (ii) an opinion on the likelihood of success, (iii) citations to specific statutes and cases that support your position, and (iv) an estimate of the cost involved to litigate. In addition, it is advisable to communicate with respected physicians in your community.

Be mindful that in the cases with private payers, their contracts provide them great latitude and protection with respect to business operations.

AAFP designed this protocol to assist its members in their efforts in maintain practicing their full scope of services when challenged by a third party. It neither guarantees success nor commits direct AAFP involvement.

(NOTE: Neither the AAFP nor its constituent chapters provide individual legal advice, nor are they responsible for financial support for legal expenses. The Academy may have data available on similar cases that may be of assistance to you.)

Direct any questions regarding this protocol to the Private Sector Advocacy staff in the AAFP Practice Support Division at 1-800-274-2237, ext. 4172.