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1 1 AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES 2 3 4 Resolution: 219 5 (A-09) 6 7Introduced by: Texas Delegation 8 9Subject: Out-of-Network Payments 10 11Referred to: Reference Committee B 12 (Monica C. Wehby, MD, Chair) 13 14 15Whereas, Health insurance companies and self-insured plans, through their third-party 16administrators, are offering fixed-fee schedules or “take it or leave it” fee schedules to 17physicians, with no chance of negotiations; and 18 19Whereas, More and more physicians are choosing to go out of network; and 20 21Whereas, The Attorney General (AG) of New York (NY) investigated and settled with 22UnitedHealth Group and its for-profit subsidiary Ingenix, which sells out-of-network rates to 23health insurance companies; and 24 25Whereas, The NY AG’s investigation showed that the Ingenix information was on average 28 26percent lower than usual, customary, and reasonable charges throughout different regions of 27the United States and agreed to stop this service to insurance companies; and 28 29Whereas, Many health insurance companies use Ingenix data for out-of-network pricing which is 30costing Texas patients more money out of pocket; and 31 32Whereas, Our American Medical Association (AMA) has joined a class-action lawsuit with other 33state associations against CIGNA, Aetna and WellPoint for using flawed Ingenix information; 34and 35 36Whereas, Patient responsibility for out-of-network services is not clearly transparent in the 37benefit communication to patients from the health insurance company; therefore be it 38 39RESOLVED, That our American Medical Association support state and federal legislation and 40regulation mandating clear and transparent health insurance company language so that prudent 41lay persons know their financial responsibility when receiving care out of network (Directive to 42Take Action); and be it further 43 44RESOLVED, That our AMA seek legislation and regulation necessary to assure clear and 45transparent language describing patient financial responsibility for patients covered by self46funded ERISA plans subjecting such plans to stricter regulation by the US Department of Labor, 47Internal Revenue Service (IRS), and US Attorney General. (Directive to Take Action). 48 49Fiscal Note: Implement accordingly at estimated staff cost of $18,688. 50 51Received: 05/06/09 52 2

3 Resolution: 219 (A-09) 4 Page 2 5 6 1RELEVANT AMA POLICY 2 3D-180.985 Health Plan and Insurer Transparency 4Our AMA will: (1) continue to closely monitor any new "transparency" programs unveiled by 5health plans to determine the impact on physicians; (2) communicate to health plans, employers 6and patients our concerns about current "transparency" programs, and educate them about 7"true transparency"; and (3) continue to educate physicians about the complexities of claims 8adjudication and payment processes to enable them to more efficiently manage their practices. 9(BOT Rep. 19, A-06; Reaffirmation A-07)

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