Action taken to reduce claim denial, allow audit equity

Honolulu -- When Gregory Cooper, MD, a family physician in Cynthiana, Ky., writes a prescription for an antidepressant, the patient's insurance company may deny reimbursement. Although treatment of many forms of depression is widely considered to be well within the purview of primary care physicians, the insurer may refuse to pay the claim because Dr. Cooper is not a psychiatrist.

"I'm trained to treat depression, and it's a very common diagnosis in my practice," said Dr. Cooper, an AMA delegate.

This situation, where payment is denied solely because of a physician's specialty, is what the AMA wants to work toward eliminating, according to policy approved at the Association's Interim Meeting in December 2003.

The policy calls for the AMA to support "appropriate action" at the state and federal levels to ban such denials, while also actively discouraging insurance companies from continuing this practice.

"There are many things that do not need specialty care," said John C. Nelson, MD, MPH, AMA president-elect and an obstetrician-gynecologist from Salt Lake City. "For example, if a person came to me with a scar on her abdomen from a previous surgery, I have the ability to revise that scar, particularly if I'm doing another procedure. If that scar were on a person's face, I'm not going to touch that because that's a very technical area that needs to be dealt with correctly. I know my limits."

Many specialists supported the policy because it goes beyond finances and restricts access to care, especially when the required specialist may not be accessible or be in short supply.

"There are unfair restrictions that are not wise," said Michael Miller, MD, an addiction medicine specialist and a Wisconsin delegate. "In the area of addiction, there's no way the problem of alcoholism in this country is going to be treated only by addiction medicine specialists. There's not enough of us. There never will be. Primary care is where it's at, and for family physicians being unable to code for alcoholism in their practice is crazy."

The denials also add another layer of hassle for the patient.

Many physicians perceive these kinds of incidents as insurers trying to practice medicine.

"It's unfair to patients, and imposes an unnecessary hurdle," said Dr. Nelson. "We're the ones licensed to practice medicine, not the insurance company."

In addition to ending denial based on specialty, the AMA would also like insurers and physicians to have a more equal relationship.

Call for refunds

A separate policy adopted by the Association calls for legislation to instruct insurers to refund for undercoding or balance it against any overcoding discovered during the course of an audit.

Insurers during audits frequently demand money back if overcoding is discovered. However, undercoding rarely, if ever, results in additional payment or is even subtracted from the overcoding.

"I was talking to a professional coder, and she noted to me that many times the overcodes are more than balanced out by the undercodes," said Virginia Hall, MD, an obstetrician-gynecologist and a Pennsylvania delegate. "If we can ask insurers to refund what we did not code for properly, audits will not be an opportunity to pick the pockets of the physician."

According to the new policy, overcoding should be balanced with undercoding, and any excess caused by undercoding should be paid to the physician, just as overcoding results in payments to the insurer.

"Let's be fair," said Dr. Nelson. "The insurers have an amazing ability that if someone is deemed to have upcoded, the insurance companies are right there. What about the opposite side of that? Why shouldn't the doctor be able to get back what was withheld."

In other action, the AMA said physicians should avoid financial incentives that would result in inappropriate denial of care.

The Association also endorsed health reimbursement arrangements as a means to give patients greater control over their health care decision-making.

Currently, HRA accounts can be offered by any employer and consist of a "notional" account through which medical expenses are reimbursed. The AMA stated in a report that such accounts, however, should be improved and should be made real, owned by the employee rather than the employer, and rolled over from year to year. Such accounts also should be portable.