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1 AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES 2 3 Resolution: 215 4 (A-09) 5Introduced by: Missouri Delegation 6 7Subject: Insurance Companies Use of Contractors to Recover Payments 8 9Referred to: Reference Committee B 10 (Monica C. Wehby, MD, Chair) 11 12 13Whereas, Insurance companies adhere to set time limits of no more than 180 days for 14physicians to submit claims for care they render to their patients; and 15 16Whereas, Several major insurance companies have recently employed contractors to recover 17payments on old claims past one year deadline for repayment; and 18 19Whereas, The contractors often send letters asking for monies back erroneously and when 20contacted by their listed phone numbers or by mail no satisfactory explanation or appeal 21process is given; and 22 23Whereas, The contractors essentially harass physicians improperly and provide no recourse for 24physicians to dispute these “recovery” claims; and 25 26Whereas, The contractors are thought to be employed by the insurance companies as their 27listed phone number is that of the insurance companies even though their letterheads list 28different names; and 29 30Whereas, The contractors do not always use the accepted standard for bundling and multiple 31procedures, but rather their own guidelines that providers are not privy to, creating generally 32unacceptable and egregious denial of payment for services rendered; therefore be it 33 34RESOLVED, That our AMA seek legislation to limit insurance companies, their agents, or any 35contractors from requesting payment back on paid claims to no more than 90 days after 36payment is made (Directive to Take Action); and be it further 37 38RESOLVED, That such legislation require insurance companies, their agents, or any contractors 39to have a defined and acceptable process for physicians to dispute these maneuvers to get 40payment back on claims already processed, verified, and paid (Directive to Take Action); and be 41it further 42 43RESOLVED, That such legislation ban insurance companies, their agents or contractors from 44using re-pricers and re-reviewers and to adhere to their own pricing and reviewing guidelines as 45agreed upon in their contracts with physicians (Directive to Take Action); and be it further 46 47RESOLVED, That our AMA pursue legislation to end ERISA preemption of state laws to regulate 48self-insured plans in this regard and apply the same rules to Medicare and other federal plans. 49(Directive to take Action) 50 51Fiscal Note: Implement accordingly at estimated staff cost of $3,047. 52 53Received: 04/22/09 54

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Resolution: 215 (A-09) Page 2

1RELEVANT AMA POLICY 2 3H-70.926 Reasonable Time Limitations on Post-Payment Audits and Recoupments by Third Party Payers - Our AMA 4policy is that post-payment audits, post-payment downcodes and other similar requests for recoupment by third party payers be 5made within one year of the date the claim is submitted or within the same amount of time permitted for submission of the claim, 6whichever is less. (Res. 815, A-01; Reaffirmation I-04; Reaffirmation A-08) 7 8H-265.998 Guidelines for Due Process - While it is not possible to develop universal guidelines for due process, voluntary 9utilization of the following general guidelines for due process, adapted in each instance to suit the circumstances and conditions 10of the health care organization and within the requirements of the applicable laws of the jurisdiction, should assist in providing 11the type of hearing which the law in each jurisdiction requires: (1) The physician should be provided with a statement, or a 12specific listing, of the charges made against him or her. (2) The physician is entitled to adequate notice of the right to a hearing 13and a reasonable opportunity of no less than 30 days to prepare for the hearing. (3) It is the duty and responsibility of the 14hearing officer to conduct a fair, objective, expeditious and independent hearing pursuant to established rules. (4) The rules of 15procedure should clearly define the extent to which attorneys may participate in the hearing. (5) The physician against whom the 16charges are made should have the opportunity to be present at the hearing and hear all of the evidence against him or her. (6) 17The physician is entitled to the opportunity to present a defense to the charges against him or her. (7) To the extent feasible, the 18hearing panel should evaluate the issues and evidence presented related to the proposed corrective action while blinded to the 19patient outcome. (8) The hearing panel should render a decision based on the evidence produced at the hearing. (9) The 20hearing panel should include in its decision the conclusions reached and actions recommended and, as an important focus if 21feasible, remedial steps for the physician and for the health care facility itself. When feasible, the hearing panel should include 22terms that permit measurement and validation of the completed remediation process. (10) The hearing panel should endeavor to 23state its findings, the clinical basis and support for its findings, its recommendations, and actions as clearly as possible. (11) 24Within 10 days of the receipt of the hearing panel’s decision, the physician, medical executive committee or health care 25organization, if it brought the correction action, has the right to request an appellate review. The written request for an appellate 26review shall include an identification of the grounds for appeal and a clear and concise statement of the facts and/or evidence in 27support of the appeal. The grounds for an appeal of the decision shall be: (a) substantial non-compliance with the procedures 28required in the medical staff bylaws; or (b) the decision is against the manifest weight of the evidence. If an appellate review is to 29be conducted, the appeal board shall schedule the appellate review and provide notice to the physician, medical executive 30committee and the health care organization. The MEC shall appoint an appeal board consisting of members of the medical staff 31who did not sit on the original hearing panel, or, at the request of the MEC, the governing body or at least three members thereof 32may sit as the appeal board. The appeal board shall consider the record of the hearing before the hearing panel. If the appeal 33board determines that significant relevant evidence, which could bare on the outcome of the proceeding, was not entertained by 34the hearing panel, it may refer the matter back to the hearing panel for further deliberation or, at the appeal board’s discretion, it 35may receive and consider the new evidence. Similarly, if the appeals board determines that there was not substantial 36compliance with the hearing procedures in the medical staff bylaws, the appeal board may refer the matter back to the hearing 37body or, at the appeal board’s discretion, it may convene additional hearings to correct any defect in the process. Upon 38completion of the appeal board’s deliberations, the appeal board shall present its recommendation(s) to the governing body as 39to whether the recommendations(s) of the hearing body should be affirmed, modified, or reversed. (12) In any hearing, the 40interest of patients and the public must be protected. (BOT Rep. II, A-80; Reaffirmed: Sunset Report, I-98; Amended: BOT Action 41in response to referred for decision BOT Rep. 23, A-05; Reaffirmed: Res. 12, A-06) 42 43H-285.915 AMA Policy on ERISA - Our AMA will seek, through amendment of the ERISA statute, through enactment of 44separate federal patient protection legislation, through enactment of similar state patient protection legislation that is uniform 45across states, and through targeted elimination of the ERISA preemption of self-insured health benefits plans from state 46regulation, to require that such self-insured plans: (1) Ensure that plan enrollees have access to all needed health care services; 47(2) Clearly disclose to present and prospective enrollees any provisions restricting patient access to or choice of physicians, or 48imposing financial incentives concerning the provision of services on such physicians; (3) Be regulated in regard to plan policies 49and practices regarding utilization management, claims submission and review, and appeals and grievance procedures; (4) 50Conduct scientifically based and physician-directed quality assurance programs; (5) Be legally accountable for harm to patients 51resulting from negligent utilization management policies or patient treatment decisions through all available means, including 52proportionate or comparative liability, depending on state liability rules; (6) Participate proportionately in state high-risk 53insurance pools that are financed through participation by carriers in that jurisdiction; (7) Be prohibited from indemnifying 54beneficiaries against actions brought by physicians or other providers to recover charges in excess of the amounts allowed by 55the plan, in the absence of any provider contractual agreement to accept those amounts as full payment; (8) Inform 56beneficiaries of any discounted payment arrangements secured by the plan, and base beneficiary coinsurance and deductibles 57on these discounted amounts when providers have agreed to accept these discounted amounts as full payment; (9) Be subject 58to breach of contract actions by providers against their administrators; and (10) Adopt coordination of benefits provisions 59applying to enrollees covered under two or more plans. (CMS Rep. 6, I-96; Reaffirmation A-97; Reaffirmed: Rules and Cred. 60Cmt., I-97; Reaffirmed by Sub. Res. 202, A-98; Reaffirmation I-98; Reaffirmation A-99; Reaffirmed: Res. 238, A-00; 61Renumbered: CMS Rep. 7, I-05)