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1 1 AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES 2 3 4 Resolution: 118 5 (A-09) 6 7Introduced by: Texas Delegation 8 9Subject: Transparency of Preventative Care Services 10 11Referred to: Reference Committee A 12 (Steve E. Larson, MD, Chair) 13 14 15Whereas, Physician offices and our insured patients are uncertain of what is covered for 16preventive care services and recommended vaccines; and 17 18Whereas, Important preventive care services and vaccines may be delayed or payment not 19made for completed services; therefore be it 20 21RESOLVED, That our American Medical Association seek legislation requiring insurance 22companies to adopt standardized, readily accessible and understandable terminology spelling 23out coverage for preventive care services, including adequate payment for recommended 24vaccine products and services. (Directive to Take Action) 25 26Fiscal Note: Implement accordingly at estimated staff cost of $1,188. 27 28Received: 05/06/09 29

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3 Resolution: 118 (A-09) 4 Page 2 5 6 1RELEVANT AMA POLICY 2 3D-180.984 Payer Measures for Private and Public Health Insurance 4Our AMA will work with state medical associations, employer coalitions, physician billing 5services, and other appropriate groups to evaluate on an annual basis and recommend 6standards for "payer measures" for the insurance industry and government payers to be publicly 7reported for consumers that may include information such as: 1. Number of patients enrolled 2. 8Total company and individual plan revenue/expense and profit 3. Procedures covered and not 9covered by policy 4. Number of primary and specialist physicians 5. Number of denied claims 10(and %) a. Number denied based on "pre-existing condition" b. Number denied and later 11allowed c. Number denied for no reason 6. Waiting time for authorization of common procedures 127. Waiting time for authorization of advanced procedures 8.Waiting time for payment 9. 13Morbidity and mortality due to denied or delayed care 10. Number of appeals by customers or 14physicians 11. Number of successful appeals by customers or physicians 12. Number of 15consumer complaints 13. Number of government fines/sanctions 14. Use of economic profiling 16of physicians to limit physicians on panel 15. Use of quality measures approved by qualified 17specialty societies (Res. 703, I-06; Reaffirmation A-07; Reaffirmed in lieu of Res. 828, I-08) 18 19D-180.985 Health Plan and Insurer Transparency 20Our AMA will: (1) continue to closely monitor any new "transparency" programs unveiled by 21health plans to determine the impact on physicians; (2) communicate to health plans, employers 22and patients our concerns about current "transparency" programs, and educate them about 23"true transparency"; and (3) continue to educate physicians about the complexities of claims 24adjudication and payment processes to enable them to more efficiently manage their practices. 25(BOT Rep. 19, A-06; Reaffirmation A-07)

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