Principles and managed care: Not mutually exclusive

The AMA has released an updated version of its Principles of Managed Care, and the new edition is available at the Association's Web site. That should make it easy to find for doctors, patients and, perhaps most importantly, for health plans.

This is the fifth version of the Principles -- a compendium of AMA polices and ethical opinions, first published in 1993. Its goal is to "promote effective managed care techniques that are fair and equitable to physicians in ensuring high quality health care services to patients."

The latest version contains 16 sections on key topics such as disclosure provisions, credentialing and recredentialing, selective contracting, disease management, and Medicare and Medicaid managed care.

One section of the Principles sure to get some renewed attention is the section on independent and external reviews.

In June 2004, the U.S. Supreme Court struck down a Texas law allowing patients to sue their health plans in state court. The ruling effectively closes that avenue of redress for treatment denials to the millions of patients covered by employer-sponsored health plans that fall under the federal Employee Retirement Income Security Act of 1974. As a result, patients covered by and physicians contracting with those plans who want to challenge managed care decisions have only the independent and external review process.

As stated in the Principles, managed care plans should establish a procedure whereby a physician has an opportunity to appeal a claim denied for lack of medical necessity. That appeal should be heard by a medical consultant or peer review group that is independent of the organization conducting or contracting for the initial review.

In addition, the Principles outlines nine basic components that an external review procedure should include. Among them: Grievances involving adverse determinations can be submitted by the policyholder, the policyholder's representative or attending physician; independent reviewers practicing in the same state should be used whenever possible; and the results of external review should be available for public scrutiny.

New to the 30-page document are sections on claims submission and medical care "carve-outs" -- areas that have become the focus of enough AMA policy statements to warrant their own section.

These new sections mirror their predecessors in conciseness and clarity.

One example from the claims submissions principles: Practitioners should have free choice, without penalty, to transmit claims data either by paper claim or electronically.

If the health plan powers that be haven't already done so, they should read through this fifth edition of the Principles and use it to create or revise their own policies and procedures.

Managed care is not the same entity it was when the first edition of the Principles was published in 1993. But it has not abandoned many of the practices that restrict access to services or create payment hassles for and place undue administrative burden on physicians. In implementing the principles, health plans could put an end to those practices and reintroduce civility, efficiency and integrity to a process in which they are often sorely missed.