265.000 REIMBURSEMENT

265.802           Update the Status of Virtual Credit Card Policy, EFT Fees, and Lack of Enforcement of Administrative Simplification Requirements from CMS

MSSNY will request that our AMA report at the Interim 2024 Meeting on the progress of implementation of AMA Policies D-190.970, H-190.955, and D-190.968. (HOD 2024 – 267)

265.803           Safeguards Against Reduction in NYSHIP Physician Benefits

MSSNY will advocate for:

(1) requiring clear education of state employees so that there is complete transparency in the proposed sharp reduction in their healthcare benefits;.

(2) requiring NYSHIP plan to offer at least one plan to employees that reimburse out-of-network physician services at UCR (90th percentile FAIR HEALTH).

(3) preventing the ability of the Department of Civil Services to automatically apply collectively negotiated health plan changes to non-union employees if such changes would decrease coverage or reimbursement.

(4) requiring approval by the state legislature of any reduction in NYSHIP healthcare benefits. (HOD 2023-257)

265.804           Withdraw and Amend Virtual Credit Card Policy

MSSNY will advocate that the AMA officially informs HHS/CMS, updates all its written materials and communications to strike any reference to VCC as a “valid” method of healthcare electronic payment method, and removes any reference that health plans can impose the requirement to accept VCCs via contractual terms as that would be an illegal requirement in violation of HIPAA Administrative Simplification Requirements; the only legally adopted healthcare payment standard is ACH EFT; and that the AMA refers to VCC as an “illegal” or “not legal” electronic method of healthcare payments.

MSSNY will advocate that the AMA officially informs HHS/CMS, updates all its written materials and communications to strike any reference to any EFT fees imposed by health plans or health plan business associates, whether “service fees” or any other fees as “permitted,” “legal,” or “valid,” and that the AMA will remove any reference that health plans can impose “customer service fees” or support fees” on standard healthcare ACH EFT payments as that would be illegal fees in violation of HIPAA Administrative Simplification Requirements; further, the AMA communicate the position that physicians should decline by default any paid services from health plans or health plan associates as they have never been a good or fair value. (HOD 2023-62)

265.805           AMA Advocacy Philosophy – Speak Softly and Carry a Big Stick

The Medical Society of the State of New York will continue to work with the American Medical Association Litigation Center to, within appropriate financial means, identify and participate with litigation challenging private and public payor claims adjudication processes that adversely impact patient care delivery and violate existing federal and state laws. (HOD 2023-64)

265.806           Complexity of US Healthcare System – MSSNY & AMA Communications

The Medical Society of the State of New York will continue to work with the American Medical Association to educate the public about the excessive administrative hassles imposed by the numerous public and private health care payers that inappropriately interfere with patients accessing timely needed care and physicians being fairly paid for delivering this care. (HOD 2023-65)

(See also Abortion and Reproductive Rights, 5.000; Managed Care, 165.000; Medicare, 195.000;  Nursing Homes, 217.000; Surgery, 295.000; Vaccines, 312.000; Workers’ Compensation, 325.000)

265.807           Fair Health Database

The Medical Society of the State of New York will work together with the American Medical Association to advocate to Fair Health to ensure the continued identification of the frequency by which a particular CPT code is used.  (HOD 2022-59)

265.808           COVID Hazard Pay

The Medical Society of the State of New York will work with the American Medical Association and the federation of medicine to seek a state and/or federal program to provide hazard pay bonuses to physicians and other health care staff delivering care during a state and/or federal disaster emergency. (HOD 2022-52)

265.809           Tele-Visits and Telephone Consults

The Medical Society of the State of New York (MSSNY) will seek legislation and/or regulation to permanently establish equal payments for all patient encounters and communications, including but not limited to audio and visual visits, on par with payments for in person visits in the context of an established continuous relationship with a physician. (HOD 2022-110)

265.810           Adjustment of Premiums and Reimbursement Rates During the Pandemic

The Medical Society of the State of New York will advocate to the NYS Department of Health (DOH) Commissioner and the Commissioner of Insurance to review the business practices of all the major insurance companies.

The Medical Society of the State of New York will partner with the relevant New York State regulatory authorities and stakeholders to advocate that insurance companies adjust the premiums paid by customers to a fair level or provide them with appropriate reimbursements based on the reduction of services provided during the COVID-19 pandemic.

The Medical Society of the State of New York will partner with the relevant New York State regulatory authorities and stakeholders to advocate that insurance companies adjust their reimbursement rates to physicians, other providers and hospitals to fair and sustainable levels, adjusted by the increased costs spent by these individuals and entities during the COVID-19 pandemic, to ensure continuity of care for our entire community and particularly the most underprivileged population. (HOD 2022-100)

265.811           Value Based Payment Models, Evidence-Based Medicine and Quality of Care

MSSNY will advocate to ensure that reimbursement from a health insurer or health system for patient care not be conditioned upon following of a single set of treatment guidelines. (HOD 2022-255)

265.812           Clarification of Downgraded Modifiers for New York IndependentDispute Resolution

MSSNY will advocate with the Department of Financial Services to establish a clear mechanism to ensure that a physician submitting a surprise medical bill dispute to an Independent Dispute resolution entity is not penalized for submitting a claim that includes an appropriate modifier such as a code that recognizes the services of an assistant or co-surgeon. (HOD 2022-252)

265.813           Compensation for Vaccine Consultation

The Medical Society of the State of New York will seek legislation that compensates physicians for up to 20 minutes of counseling time for vaccination counseling.  (HOD 2020-268) 

265.814           Insurance Companies Collecting Deductibles and Copays

The Medical Society of the State of New York (MSSNY) will seek legislation such that insurance companies pay the physicians the full fee for covered services without deducting deductibles and copays and that the deductibles and copays will be collected directly from the policyholders. (HOD 2020-269) 

265.815           Bundling Physician Fees with Hospital Fees

MSSNY opposes bundling of doctor payments with hospital payments unless the doctor agrees to it in advance. This resolution will also be transmitted to AMA. (HOD 2020-258) 

265.816           Payment for Regadenson (Lexiscan)

MSSNY will petition the Department of Health and the Department of Financial Services to investigate the disparity between the cost of medical agents and reimbursement by insurance companies and develop a solution so physicians are not financially harmed when providing medical agents. MSSNY will bring this to the attention of the AMA to have CMS do the same.  (HOD 2020-256) 

265.817           MSSNY and AMA Position on All Payer Database Creation

MSSNY will advocate that any All Payer Database should separate out payments from different payers, such as Medicare, Medicaid, and private payers.  MSSNY will submit a resolution to the AMA requesting it advocate for any All Payer Database to provide true payments which hospitals are making to their employed physicians, not just the amount of payment that the insurer is making on the physicians’ behalf to the hospital.  (HOD 2020-60)

265.818           CARES Equity Act and Loan Forgiveness in the Medicare Accelerated Payment Program

The Medical Society of the State of New York will continue to work with the American Medication Association and the federation of medicine to improve and expand various federal stimulus program (i.e. Coronavirus Aid, Relief, and Economic Security (CARES) Act) to assist physicians in response to the Covid-19 pandemic, including:

• Re-starting the suspended Medicare Advance payment program, including significantly reducing the re-payment interest rate and lengthening the repayment period
• Expanding the CARES Act health care provider relief pool, and working to ensure that a significant share of the funding from this pool is made available to physicians in need regardless of the type of patients treated by those physicians
• Reforming the Paycheck Protection Program, to ensure greater flexibility in how such funds are spent and lengthening the repayment period.

The Medical Society of the State of New York (MSSNY) will ask that the AMA, in the setting of the COVID-19 pandemic, advocate for additional relief to physicians via loan forgiveness for medical school educational debt. (Amended and adopted, Council 6/4/20; HOD 2020-EM 5 & EM 6)

265.819           Urgent Care in the Doctor’s Office

The Medical Society of the State of New York will advocate for increased payment for office based afterhours CPT Codes.  (HOD 2019-255, referred to Council. Amended and adopted 9/2019)

265.820           Site Neutral Physician Payment Equality

The Medical Society of the State of New York will urge, advocate and seek legislation that seeks parity of government funding and payment methodologies among sites of care.  (HOD 2019-113 and 2019-121) 

265.821           Maintaining the Integrity of Fair Health

The Medical Society of the State of New York will forward a resolution to the AMA Annual House of Delegates urging that any legislation addressing surprise out of network medical bills use Fair Health usual and customary data and not All Payer Database data.  (HOD 2019-66) 

265.822           Air Ambulances

The Medical Society of the State of New York supports state and/or federal legislation to establish an independent dispute resolution system to resolve payment disputes between emergency air ambulance providers and health insurers, similar to the “expedited arbitration” process used to determine payment for out of network emergency and “surprise” hospital bills in New York; such independent dispute resolution process should ensure that the patient be “held harmless” except for applicable insurance policy in-network cost-sharing requirements.  This resolution will also be transmitted to the American Medical Association for consideration at its next House of Delegates meeting. (HOD 2019-65)

265.823           Overpayment Recoveries on Historically Paid Services and the “Restatement of the Law of Restitution”

The Medical Society of the State of New York will work with its legal counsel to assess the validity of various legal principles to assist physicians in challenging health insurer payment recovery attempts, such as legal challenges based upon the principles of estoppel and restitution.  (HOD 2019-63)   

265.824           Physician Reimbursement All Practices

The Medical Society of the State of New York will advocate to the New York Department of Financial Services that approved premium increases granted to health insurers are fairly allocated towards increased spending on patient care services delivered by physicians. (2019-62

265.825           Financial Penalties and Clinical Decision Making

The Medical Society of the State of New York opposes the practice of a payer utilizing statistical targets to determine the cost-effectiveness of a therapeutic choice and imposing financial penalties upon individual physicians and/or associated physicians based upon use of statistical targets without first considering the clinical factors unique to each patient’s claim. This resolution will be transmitted to the American Medical Association for consideration at its next House of Delegates meeting.  (HOD 2019-60) 

265.826           Compensation to Reflect the True Cost of Providing Information

MSSNY will seek legislation or regulation which require fair compensation for the information requested by governmental agencies for their registries and research purposes, and that this compensation reflect the true cost of providing information.  (HOD 2019-264) 

265.827           Payment for Medications Used Off Label for Treatment of Pain

The Medical Society of the State of New York will seek passage of state regulation and/or legislation which mandates that third party payers, as well as Centers for Medicare Services (CMS), allow reimbursement for off label use of medications like gabapentin or lidocaine patches at the lowest copayment tier so that patients can effectively be treated for pain and decrease the number of opioid prescriptions written.  MSSNY will also have AMA petition CMS to allow reimbursement for off label use of these medications so that patients can be effectively treated for pain and decrease the number of opioid prescriptions written.  (HOD 2019-262)

265.828           Reimbursement for Health Information Technology

The Medical Society of the State of New York will seek passage of state regulation and/or legislation that mandates third party payers allow physician practices to charge a technology fee to the payer equal to the copayment of the patient’s plan.  MSSNY will also send a resolution to the American Medical Association to seek passage of federal regulation and/or legislation that mandates third party payers allow physician practices to charge a technology fee to the payer equal to the copayment of the patient’s plan.  (HOD 2019-256)  

265.829           Obtain Reimbursement for Medical Clearance Codes

MSSNY recognizes and will educate payers on the importance and extra effort that is being put forth as far as time, liability and inconvenience on the part of primary care physicians; and that in fairness to primary care physicians, MSSNY will intercede with certain payers in Western New York to ensure that medical clearance codes be “carved out” and reimbursed separately in addition to the global payment. (HOD 2019-253)

265.830           Capitation Carve Outs for High-Value Primary Care Services

MSSNY recognizes that care transition visits and preoperative consultation visits should not be included in global capitation budgets in primary care capitation payment models but should be paid on a fee for service basis carved out from the global capitation budget.  Care transition visits and preoperative consultation visits should have unique CPT codes allowing those visits to be identified to insurers when such services are submitted for payment.  MSSNY will actively support carving out both care transition and preoperative consultation visits from global primary care capitation rates, continuing fee for service payments at appropriate reimbursement levels for both of these services by educating physicians and insurers about this issue, and supporting and assisting efforts to make these adjustments in any capitation programs that have not already carved out these services. (HOD 2019-252)

265.831           Prohibit Retrospective ER Coverage Denial

The Medical Society of the State of New York will work to ensure strong enforcement of the New York and federal laws that require health insurance companies to cover emergency room care when a patient reasonably believes they are in need of immediate medical attention, including the imposition of meaningful financial penalties for insurers who do not follow the law.  This resolution will be submitted to the AMA.  (HOD 2018-57) 

265.832           Emergency Out of Network Services

The Medical Society of the State of New York will work with the American Medical Association to pursue legislation or regulation which will require health plans not regulated by the State of New York to pay physicians for emergency out-of-network care at least at the 80^th percentile of charges for that particular geo-zip as reported by the Fair Health database.  This resolution will be forwarded to the AMA.  (HOD 2018-55; Reaffirmed HOD 2019 in lieu of res 67; Reaffirmed in lieu of HOD 2020-58)

265.833           Fair Health Transparency

The Medical Society of the State of New York will continue to work with Fair Health to ensure appropriate transparency and fairness in the collection and presentation of its usual and customary charge data, as well as appropriate representation by practicing primary and specialty care physicians on the Fair Health Board of Directors.  (HOD 2018-54; Reaffirmed HOD 2019-66; Reaffirmed HOD 2022-59)

265.834           Rebalancing of Facility and Service Fees

The Medical Society of the State of New York will advocate for legislation or other regulatory mechanisms to eliminate unjustified discrepancies in payment schedules across different sites of service with the goal of creating more equitable payment schedules. (HOD 2018-53; Reaffirmed in lieu of resolution 58 – 2024 HOD)

265.835           No-Fault Pre-Authorization Requirement

The Medical Society of the State of New York will seek through legislative and/or regulatory means a requirement that No Fault car insurance companies confirm coverage and provide pre-determination when requested by the treating physician and other providers in accordance with the same time frames for elective diagnosis and treatment that commercial payers are required to follow.  MSSNY will seek through legislation and/or regulation the assurance of payment pre-determined services.  (HOD 2018-265) 

265.836           House Calls Instead of Certain Paratransit Visits

The Medical Society of the State of New York will seek legislation or regulation whereby a physician making a house call on a patient who would otherwise travel to a medical practice, would be separately compensated by the fund that provides for patient transport.  MSSNY will include in its legislative or regulatory proposals that the physician transit fee be paid regardless of the patient’s health insurance (with the physician not permitted to bill the health insurance for the transit service).  (HOD 2018-259) 

265.837           Use of High Molecular Weight Hyaluronic Acid

The Medical Society of the State of New York will advocate for reimbursement and coverage for high molecular weight hyaluronic acid intra-articular injections as appropriate care and treatment for patients with mild to moderate osteoarthritis of the knee.  This resolution will also be forwarded to the AMA.  (HOD 2018-258) 

265.838           Office Based Surgical Facility Fee Reimbursement

The Medical Society of the State of New York will request the NYS Department of Health (DOH) and the NYS Department of Financial Services (DFS) to inform officially the private insurance carriers in New York State that office-based surgical facilities, which operate under the license of the physician owner, are in fact regulated by New York State and are not permitted to function without the oversight of the NYS DOH.  MSSNY will seek legislation and/or regulation supporting reimbursement of Office Based Surgical Facility fees by private insurance carriers.  (HOD 2018-257) 

265.839           Non-Payment and Audit Takebacks by CMS

Through legislation and/or regulation, the Medical Society of the State of New York will seek policies opposing nonpayment of claims due to minor wording or clinically insignificant documentation inconsistencies, extrapolation of overpayments based on minor consistencies and denial of bundled payments based on minor wording or clinically insignificant documentation inconsistencies.  This resolution will also be sent to the AMA.  (HOD 2018-253) 

265.840           All Payer Database (APD) Not Appropriate as Reimbursement Standard

The Medical Society of the State of New York will ensure that the payment data collected in an All Payer Database (APD) NOT form the basis for a reimbursement standard to health care providers, because the APD does not include payment data from ERISA plans, which results in an artificial narrowing of the range of fee data collected by the APD.  (HOD 2017-60)

265.841           Collection of Deductible and Co-Insurance

Seeking enactment of legislation or regulation if necessary, the Medical Society of the State of New York will ensure that:

Health insurance companies and their vendors provide easy to understand written notice to their enrollees regarding out of pocket costs they may face in their insurance coverage;

A physician’s office can easily and accurately determine a patient’s out of pocket costs from their health insurer;

Physicians are permitted to collect out of pocket costs from patients at the time of delivery of services, as well as waive collection of such costs when warranted based upon each patient’s circumstances. (HOD 2017-58)

265.842           Study and Promotion of Telemedicine Payment Parity

MSSNY will work with individual legislators throughout the state to introduce legislation that would require parity of payment between services provided in-person and via telemedicine.  (HOD 2017-109; Reaffirmed HOD 2019 in lieu of res 105)

265.843           Copying and/or Scanning Costs

MSSNY will forward a resolution to the AMA to seek changes to the federal HIPAA regulations so that charges related to providing patient records defer to state law for searching, retrieval and matters relating to determining charges which may be imposed for providing patients with medical records.  (HOD 2017-102) 

265.844           Office Based Surgery Reimbursement

The Medical Society of the State of New York will seek legislation to require health plans to provide facility fee reimbursement to physicians and/or medical practices that obtained State-mandated accreditation for their office-based surgical suite(s).  The new legislation should mandate that facility fee reimbursement paid to physicians and/or medical practices issued by the health plan be fair and equitable, which means that payment by plans be no less than 50% of the rate paid to Ambulatory Surgical Centers (ASCs) or Hospitals for the room use of the ER, OR, OPD or Clinic, which will enable the plans to realize cost containment savings by paying physicians and/or medical practices, rather than paying the full ASC or Hospital room use rate.  (HOD 2017-255; Reaffirmed HOD 2018-53)

265.845           Reimbursement for In-Office Administered Drug

MSSNY will take the necessary steps to ensure that in-office physician administered medications be reimbursed at no less than the cost of the medication, which includes the cost of the purchase, storage, spoilage and professional administration. (HOD 2017-251)

265.846           Expansion of Independent Dispute Resolution Process

MSSNY will seek legislation and/or regulation to require the New York Department of Financial Services to create and Independent Dispute Resolution process, similar to that established under the 2014 law for resolving emergency and “surprise” out of network claims, to resolve allegations of inappropriate care denials or reductions in payment by health insurers that cannot be resolved timely through existing statutory relief processes.  (HOD 2016-53; substitute resolution adopted Council Nov 3, 2016

265.847           Arbitrary Relative Value Decisions by CMS

The Medical Society of the State of New York (MSSNY) will work with the AMA, other state medical and specialty societies and the national specialty societies, to change federal law by creating new checks and balances in the Centers for Medicare and Medicaid Services (CMS) regarding the Relative Value scale and other fee determination methodologies; and providing an appeal process both within CMS and the courts regarding fee and Relative Value determinations for specific procedures. (HOD 2016-265) 

265.848           Ensuring Physicians Get a Fair Share of Bundled Payments

The Medical Society of the State of New York will pursue regulation or legislation in the State of New York to fairly compensate the voluntary/private physicians for the work that they do at the hospital and share the bundled payment with the voluntary/private physician in at least the same proportion to the employed physicians in the same geographic area. (HOD 2016-264) 

265.849           Development of a CPT Code for PMP Look-Up

Since 2013, New York State has required that physicians check the Department of Health (DOH) Prescription Monitoring Program (PMP) registry prior to prescribing or dispensing any Schedule II, III or IV controlled substances, a process which is not currently reimbursable but involves physicians’ time and medical judgment in consideration of providing controlled prescription medications; the New York Delegation will submit a resolution to the 2016 Annual AMA House of Delegates, calling for the development by the AMA and CMS of a Current Procedural Terminology (CPT) code so physicians in all States can be appropriately paid for their time and effort in consulting the PMP registry. (HOD 2016-253)

265.850           UCR-Based Out-Of-Network Policies

MSSNY will continue to advocate strongly for preservation and expansion of usual, customary and reasonable (UCR) based out-of-network benefits available to our patients; and energetically and proactively educate physicians on the importance of a meaningful UCR-based out-of-network environment in order to maintain an acceptable practice environment for physicians desiring to practice in-network as well as those physicians who are employed by an institution.

MSSNY will include in the educational materials, the identification of access to other information including links to social media as well as successfully implemented business strategies concerning how the meaningful UCR-based out-of-network environment may be a viable option for physicians who wish to maintain independent out-of-network practices.

MSSNY will proactively educate patients, employer groups and insurance agents on a UCR- based out-of-network plan. (HOD 2016-105 & 106)

265.851           Medicare and Insurance Takeback Procedures

The Medical Society of the State of New York will collaborate with the Healthcare Association of New York State (HANYS) and the AMA to ensure when a patient hospitalization is retrospectively found not to meet criteria for inpatient admission, then the take back amount be only the difference between the cost of the admission and the cost of necessary observation for that patient stay. 

MSSNY will collaborate with HANYS and the AMA to ensure that, for any care provided to hospital patients who have Medicare, managed Medicare, or commercial insurance, hospitals have the option to rebill denied inpatient claims as outpatient claims, when a physician using clinical judgment makes a prospective decision to admit a patient who is later found to not meet admission criteria.

MSSNY will also advocate to ensure that the time frame for a public or private payer to audit a claim after payment be limited to the time period that a physician or hospital has to submit the claim to a public or private payer following the delivery of care.

The New York Delegation to the AMA will introduce this resolution for consideration at the next AMA Annual House of Delegates Annual Meeting. (HOD 2016-66)

265.852           Ensuring FAIRHEALTH Integrity

The Medical Society of the State of New York will continue to work with Fair Health to assure optimal physician charge data collection and presentation. (HOD 2016-59; Reaffirmed HOD 2018-54; Reaffirmed HOD 2019-66)

265.853           Underpayment Reconciliation

The Medical Society of the State of New York will seek legislation which will mandate insurers identify underpayments discovered through an audit, and return such payment to the physician with accrued interest, and if a pattern of underpayments is discovered in an insurer audit, that such findings be extrapolated across the entire time period reviewed in the audit and used to offset overpayment amounts due to the insurer. (HOD 2016-57)

265.854           Protection from Underpayment for Services

The Medical Society of the State of New York will urge the NYS Department of Health, NYS Department of Financial Services and Attorney General’s office to require health insurance companies to provide complete fee schedule information to physicians upon request; and also advocate for legislation, regulation or other appropriate policy intervention to ensure health insurers pay physicians for medical services in accordance with the fees specified in the physician’s contract even if the physician’s submitted charge is less than the fee schedule amount.  (HOD 2016-56) 

265.855           Health Insurance Guarantee Fund

The Medical Society of the State of New York will continue to advocate for the enactment of a Health Insurance Guarantee Fund to pay outstanding claims in the event of insolvency by a health insurance company.  MSSNY will also continue to advocate to ensure the availability of funds to pay the outstanding claims of Health Republic, either through a Health Insurance Guarantee Fund or use of other state monies; and the Medical Society of the State of New York will continue to work with the Department of Financial Services to ensure strong oversight of the financial integrity of health insurance companies operating in New York State.  (HOD 2016-54 & 55; Reaffirmed HOD 2019 in lieu of res 64)

265.856          Managed Care Contracts and “All Products” Clauses and Silent PPOs

As MSSNY continues to advocate for prohibition of health insurer “all product” clauses any such legislation will: (1) require that the insurer must set forth separate terms (including compensation terms) for each of the insurer’s products that exist when the contract is signed; (2) require that if an insurer introduces a new product after the contract is signed, the insurer will not be permitted to unilaterally designate the physician as a participant in that product; (3) enable that the physician be allowed to choose either to participate or not participate in that new product; and (4) ensure that if the physician chooses to participate, the insurer must reach an agreement with the physician on business terms for that new product. (HOD 2016-52)

265.857        Reimbursement for Non-Bundled Lab Tests

The Medical Society of the State of New York will seek federal legislation to ensure that as the government moves forward to value based payment and reform, that the legislature and federal agencies seek direct physician input to ensure that bundled payments result in quality care and best patient outcomes rather than concentrating solely on the cost of care.  (HOD 2015-253, substitute resolution adopted by Council, 1/21/2016)

265.858           Site of Service Parity

The Medical Society of the State of New York (MSSNY) will seek legislation or regulation which would eliminate Medicare and commercial insurance payment differentials for routine and non-emergency physician services based upon site of service and MSSNY will encourage the AMA to seek similar legislation on a national level. (HOD 2015-264; Reaffirmed in lieu of resolution 58 – 2024 HOD)

265.859           Payment for Physicians’ Work:  Appealing Insurance Company Denials for Payment

The Medical Society of the State of New York, by legislation or regulation, will seek payment for physicians’ time and effort which is involved in preparing appeals for reversal of denials of payment for medical care, procedures and medications by insurers and other third party payers on behalf of their patients.  (HOD 2015-259; Reaffirmed HOD 2021-254 and 2021-255 and 2021-253)

265.860           Right to Compensation

The Medical Society of the State of New York will seek legislation to eliminate the subsequent reversal of authorization and denial of payments for procedures that had been previously approved and when verification of eligibility had been confirmed by the Managed Care Company.  And in case of non-payment of a claim, the physician who has provided the care is entitled to obtain compensation from the patient, if he or she so chooses.  (HOD 2015-258) 

265.861           Forced Use of “Virtual” Credit Card Payments to Physicians

The Medical Society of the State of New York will educate its members, via E-news and the News of New York, that as of January 1, 2014, HIPAA regulations require health plans to offer physicians an Automated Clearing House (ACH) Electronic Funds Transfer (EFT) payment option that does not charge percentage-based fees and if a plan does not send payment by the HIPAA approved EFT ACH standard, the physician can demand that the plan revert to paper checks until such time that the HIPAA transaction standard is available. (HOD 2015-256) 

265.862           Eliminating Denials Due to Documentation of Dental Pathology

MSSNY will seek to eliminate insurance denials based on the inclusion of diagnosis codes otherwise classified as dental and require payment to the provider if the patient presented with any condition that can lead to medical concerns.  (HOD 2015-251) 

265.863           New York State Attorney General’s Office Physician Phone Call Policy

The Medical Society of the State of New York will work with the New York State Attorney General’s Office to ensure physician complaints regarding inappropriate care denials and other deceptive practices by health insurers are properly investigated.

So that physicians are aware, the Medical Society of the State of New York will routinely publish information regarding the appropriate process to file a prompt payment complaint with the New York State Department of Financial Services when insurers do not make timely payment of physician claims. (HOD 2015-66) 

265.864           Prompt Payment

The Medical Society of the State of New York will work with the New York State Department of Financial Services to ensure prompt payment complaints from physicians against health insurers are resolved expeditiously, preferably within 30 days of the complaint; and MSSNY will advocate for legislation that would increase the current prompt payment interest penalty above the current 12% per year threshold.  (HOD 2015-61; Reaffirmed HOD 2021-56)

265.865           Payment for Services to Pharmacy Benefit Managers

The Medical Society of the State of New York will ask the AMA CPT Editorial Panel to determine the necessity of developing a new CPT code for the purposes of billing insurers for necessary communications with these insurers and/or their contracted pharmacy benefit managers, or whether existing codes could be used for this purpose.  (HOD 2015-56) 

265.866           Use of Patient Satisfaction Surveys to Determine Payment for Medical Services

The Medical Society of the State of New York urges that health plans which use customer satisfaction surveys not use them to determine payment for medical services rendered but rather to educate providers in order to improve patient experiences. (HOD 2014-258; Reaffirmed HOD 2024)

265.867           Cost Concerns Used to Downgrade Physician Designation and Listing on Insurance Panels

The Medical Society of the State of New York urges health plans to use cost analysis only as an educational tool for providers and not to downgrade physician designation or listing on insurance panels.   (HOD 2014-259; Reaffirmed HOD 2024) 

265.868           USE OF GUIDELINES AS ABSOLUTE OVER CLINICAL JUDGMENT BY THE PROVIDER

The Medical Society of the State of New York will seek through legislation, regulation or other relief, a prohibition against insurers using the existence of a clinical guideline to force an appeal. (HOD 2014-108; Reaffirmed HOD 2024) 

265.869           Development of a Transparent and Fair Payment Process for ERISA Plans

MSSNY will introduce a resolution at the AMA House of Delegates seeking legislation through the Congress or through regulation by the Department of Labor which would require ERISA Plans develop and administer a transparent and fair process, similar to States prompt payment laws and CMS regulation, for the payment of claims to providers,. (HOD 2014-61; Reaffirmed HOD 2015 in lieu of res 62)

265.870:          Development of A Fair and Transparent Recoupment Process to be Used by Third Party Payers for Physicians:SUNSET HOD 2023

265.871:          Revision of AMA Current Procedure and Terminology (CPT) to reflect EHR/EMR documentation and work processes

MSSNY recommends that the AMA review the CPT coding guidelines with the aim of developing a new model of payment that reflects 21^st century EHR technology, and that the AMA make immediate revisions to the current CPT practice performance reporting process aimed at preparing the infrastructure for new models of paying for the delivery care.  (HOD 2013-268; Reaffirmed HOD 2021-252)

265.872:          Improvement in Coordination in Care in End of Life Patients

MSSNY should petition the American Medical Association to urgently provide a meaningful and continuous coordination between home, hospital and nursing home palliative processes, allowing for adequate reimbursement for all and avoiding disconnects such as the subacute wait to resume palliative care. MSSNY believes it urgently necessary that all medical insurance carriers be required to provide palliative care benefits that are consistent across all carriers and that do not create a complicated variable requirement and rules simply to hinder the process and avoid reimbursement. MSSNY also believes that nursing home palliative care reimbursement must be such that neither the nursing home nor the hospice suffers and that care can easily be coordinated within the last weeks and months of life. (HOD 2013-255; Reaffirmed HOD 2023)

265.873:          Managed Care Contract Payment Should be above Medicare Fees

MSSNY should seek legislation and/or regulation to prevent managed care companies from utilizing a physician payment schedule below the updated Medicare professional fee schedule. The MSSNY delegation to the American Medical Association (AMA) should introduce a similar resolution at the next meeting of the AMA House of Delegates. (HOD 2013-254; Reaffirmed HOD 2023)

265.874:          Use of Fair Health Database

MSSNY will advocate that any alternative payment structure of payments from private or public payors for episodes of care assure fair payments to the physicians who are providing the care, using the FAIR Health database as a reference. (HOD 2013-59; Reaffirmed HOD 2023)

265.875           Transparency in Out-of-Network Coverage

The Medical Society of the State of New York will seek legislation, regulation or other appropriate means to require greater transparency for all health insurance policies which provide out-of-network coverage so that consumers and physicians have a thorough knowledge and understanding of:

• Available benefits by the treating physicians and any restrictions on access to these benefits, either in-network or out-of-network;
• Physicians’ ability to review and discuss all available treatment options, out-of-network referrals, non-formulary medications, etc.;
• Methodology of payment and anticipated out-of-pocket expenses, etc.

And this legislation, regulation or other appropriate means should assure that health insurance companies selling out-of-network policies not be permitted to change or modify benefits or coverage provisions during the time the policy is in force. (HOD 2012-54; Reaffirmed HOD in lieu of 2017-111)

265.876           Reimbursement for Cost of Sign Language Interpreters: SUNSET HOD 2022

265.877           Clear and Definitive Definitions of Abusive Billing Practices as Stipulated in PHL 3224-b

Once a clear understanding of what is considered “abusive billing,” has been established, MSSNY will seek to have all health insurance carriers in the State of New York comply with the following provisions as agreed upon by MSSNY and United Healthcare:

• The physician will receive a letter notifying him/her that he/she has been selected for audit. The letter will explain the methodology used to make the determination.  Importantly, only those physicians who, when compared against other physicians practicing in the same specialty in the same region are deemed to be the greatest statistical outliers, will be selected for audit.  MSSNY has asked that this letter state very clearly how the physician was selected for audit;
• Carrier will initially request only two years of records selected by a random sample;
• Carrier will have the option to request agreement to toll the six years request option to reserve its right to do so at some time in the future;
• The physician will have the opportunity to challenge the findings in the claims randomly selected for the audit as to why they are “outliers;”
• The proposal outlines three possible courses of action depending upon the percentage of records reviewed that do not substantiate the services billed. Of particular note, if less than 40% of the medical records selected in the random sample do not substantiate the services billed, the only step that United will take will be conducting provider education. (HOD 2012-251; Reaffirmed HOD 2022)

265.878           Fair Compensation Mechanism for Changing Medications at Insurance Plan Request

The Medical Society of the State of New York will work towards developing a solution that equitably and safely allows medication changes to be made without penalizing the patient while fairly compensating the physician for their work involved in decision-making.  (HOD 2012-252; Reaffirmed HOD 2022)

265.879           Directing Hospital Billing Payments to Physician of Record: SUNSET HOD 2022

265.880           Time Limits for Recovery Audit Contractor (RAC) Reviews

The Medical Society of the State of New York will petition CMS to limit RAC reviews to less than one year from payment of claims and will send this resolution to the American Medical Association (AMA) at the next AMA House of Delegates (see AMA policy D-70.953). (HOD 2012-261; Reaffirmed HOD in lieu of 2017-108)

265.881           United Health Care Proposed Policy Concerning Overpayment Audits:SUNSET HOD 2023

265.882           Direct Payments to Physicians by Insurance Carriers

MSSNY will pursue regulation and/or legislation to compel third party payers to remit insurance payments directly to the non-participating physician when the insurance company is directed by the patient to do so.  (HOD 2011-252; Reaffirmed HOD 2021)

265.883           Physicians and Evidence-Based Medicine (EBM): 

MSSNY, in its deliberations and advocacy, will support the development and use of high-quality evidence-based medicine as a guide to treating patients, provided, however, that the ultimate decision for care for each patient must rest with the physician determining the most appropriate care and treatment for their patient based on the patient’s unique health care needs; and that evidence-based guidelines should not form the sole basis for health plan payment policies or liability.  (HOD 2011-65; Reaffirmed HOD 2014-108; Reaffirmed HOD 2024)

265.884           Hospital Readmissions

MSSNY will work with the Healthcare Association of New York and the Greater New York Hospital Association to amend state and federal law to exclude know and expected complications from “quality adjustment in DRG payment.”  (Denial or reduction in payment when appropriate cause has been provided.)  (HOD 2011-64; Reaffirmed HOD 2021)

265.885           Out-of-Network Reimbursement

MSSNY will support and advocate for legislation and/or regulation that:

Requires managed care organizations to use the FAIR Health benchmarks as the basis for reimbursement for out-of-network charges for any policy that provides out-of-network benefits;

Prevents health insurance companies from selling policies that purport to but, in fact, fail to adequately cover out-of-network health care benefits;

Requires health insurance companies to “crosswalk” their out-of-network reimbursement methodology to true UCR (such as that being developed under FAIR Health).  (HOD 2011-58; Reaffirmed HOD 2021)

265.886           Denying Reimbursement Based on Volume of Procedures Performed:

MSSNY is asked to challenge the Department of Health (DOH) on the current lack of quality data as it reflects solely on currently defined low volume threshold; request that the DOH re-examine the policy and reverse its denial of reimbursement based on new quantifiable data gathered since the policy has been in place; and communicate to the DOH its concern with the nature of the policy, the appeals process and the denial of reimbursement to the physicians who contract with the Medicaid fee for service and managed care Medicaid programs.  (HOD 2010-262; Reaffirmed HOD 2020)

265.887           Re-evaluation of Evaluation and Management Codes: SUNSET HOD 2020

265.888           Denial of Reimbursement Based on Volume of Procedures Peformed:

MSSNY will communicate its concern to the New York State Commissioner of Health, as well as to the Governor and State Legislature, regarding a newly implemented health department policy whereby payment for procedures or treatments performed at certain hospitals will be discontinued based on the volume performed within a calendar year, and work with the Department to monitor the impact of this policy on patient access to quality care within their community; and will create a multi-specialty work group to study the scientific relationship, if any, between low volume procedures and patient access to and the delivery of quality medical care.  (Council 11/19/09; Reaffirmed HOD 2019)

265.889           Claims Denial Although Accurately Coded: 

MSSNY will seek legislation that (1) would mandate the health care provider discuss denials based on policy, utilization or medical necessity with a physician of the insurance company rather than a non-physician representative and (2) the discussion between the health care provider and the Medical Director of the insurance company take place within a reasonable length of time after the request for such is made.  (HOD 2009-265; Reaffirmed HOD 2019)

265.890           Medical Certification Paperwork:

MSSNY will study the issue of physician reimbursement for medical certification forms and advise physicians as to the ethical and legal options available in regard to this increasingly unwieldy, time-consuming issue for physicians.  Also, MSSNY is to address the issue of medical certification paper work with third party payers and strongly urge them to provide reimbursement to physicians for the service of providing medical certification and medical reports for patients.  (HOD 2009-261; Reaffirmed HOD 2019)

265.891           Adjustments Made to Relative Value Scale to Include Increased Paperwork for Physicians:

MSSNY will seek reconsideration of Work Relative Value Units for all AMA-CPT codes from the Relative Value Update Committee (RUC) to capture the additional work forced upon physicians by voluminous documentation requirements resulting from regulatory mandates when reimbursement rates are calculated and to transmit a similar resolution to the American Medical Association seeking passage of federal regulation and/or legislation to accomplish this reconsideration. (HOD 2009-258; Reaffirmed HOD 2019)

265.892           Medical Home Model:

MSSNY will study the medical home model through an existing committee or by establishing a Task Force on Medical Home Models with these directives:

1. define medical home, including payment models, after considering American Medical Association Policy H-160.919;
2. research successful medical home pilot projects;
3. monitor the progress of medical home pilot projects in New York State;
4. make policy and legislative agenda recommendations on this subject to the MSSNY Council; and
5. develop a program to educate physicians in New York State about the opportunities and threats inherent in medical home pilot projects. (HOD 2009-94; Reaffirmed HOD 2019)

265.893           Assist Physician Practices to Move Toward Electronic Billing:  SUNSET HOD 2019

265.894  Recovery of Damages Resulting from the Use of Flawed UCR Data:

MSSNY will support efforts to recover damages due participating physicians that resulted from the use of the flawed Usual Customary & Reasonable (UCR) (Ingenix) database.  (Council 6/25/09; Reaffirmed HOD 2019)

265.895           United Health Group Policy Change:

MSSNY will contact the United Health Group immediately demanding that it halt and reverse its policy change of deletion of the use of UCR for determining reimbursement and replacement with the terminology of allowed charge and that it abide by the letter, spirit and intent of the Attorney General’s agreement, which they signed less than three months prior to MSSNY’s 2009 House of Delegates.  Also, MSSNY to contact he Attorney General’s office alerting them of the action to be taken by United Health Group in what is a clear attempt to circumvent the terms of the Ingenix agreement.  (HOD 2009-76; Reaffirmed HOD 2019)

265.896           Legal Flexibility to Offer Uninsured Patients Structured Pre-Payment

Options:

MSSNY will support innovative strategies and physician initiatives that allow or enhance universal access to medical care, including permitting physicians legal flexibility to offer otherwise uninsured patients structured pre-payment options for accessing care in their office.  (HOD 2009-65; Reaffirmed HOD 2019))

265.897           Inappropriately Constrained Provider Reimbursement, Increasing Health Insurance Premiums and Increased Patient Cost-Sharing:  (Council 3/30/08; SUNSET HOD 2018)

265.898           Universal Explanation of Benefits (EOB):

MSSNY will seek the enactment of legislation, regulation or other appropriate means to (1) require health plans to use a universal Explanation of Benefits (EOB) form for patients and physicians and (2) assure that such universal EOB form provide detailed, easily understandable explanations for patients and physicians as to why a particular claim or a portion of a claim will not be paid by a health plan.  (HOD 2008-60; Reaffirmed HOD 2009-70; Reaffirmed HOD 2019)

265.899           Payment for Procedures:

MSSNY to seek legislation, regulation or other appropriate means to require health insurers to pay for any and all procedures clinically indicated pursuant to specialty society guidelines that are prudent and unanticipated at the time of performing pre-approved procedures.  (HOD 2008-57; Reaffirmed HOD 2018)

265.900           Non-Participating Physicians Who Accept Assignment: 

MSSNY should seek to assure that legislation to protect the ability of a patient to assign payment to a non-participating treating physician also preserves the ability of such non-participating physician to be reimbursed their usual and customary fee.  (HOD 08-56; Reaffirmed HOD 2009-63; Reaffirmed HOD 2016-50)

265.901           New Federal Legislation re Prompt Payment and Amendment of New York State Prompt Payment Law:

MSSNY will work with the American Medical Association for the introduction of federal legislation that imposes a strong federal standard for prompt payment, following the AMA’s recommendations which include:

• requiring payment within 30 days for clean paper claims and 14 days for clean electronic claims;
• imposing stiffer fines than those currently in state laws, for insurers that fail to comply with the federal prompt payment law;
• requiring that interest be assessed on the amount of payment outstanding, and that interest increase with the length of time the claim has been delinquent;
• requiring that the insurer absorb any fees and costs that the physician may incur due to the lack of prompt payment of the claim, provided that the physician can document that these fees or costs might not have been incurred if the claim had been paid within the mandated timeframe.

MSSNY also will work with the AMA for a federal law that:

• sets a statutorily defined time limit for insurers to notify physicians that additional information is needed to process a claim;
• requires the insurer to specify, in the notice, all problems with the claim and give the physician an opportunity to provide the information needed;
• requires the insurer to pay any portion of a claim that is complete and uncontested.

Also, MSSNY will work towards amending New York’s Prompt Payment Law to:

• include all applicable provisions of the federal law mentioned above;
• provide that where New York law is stronger than federal law or addresses an issue that is not part of federal law, the state law should take precedence. (HOD 2008-55; Reaffirmed HOD 2015 in lieu of res 62)

265.902           Charge for Referrals and Prior Authorizations

MSSNY to seek the introduction of regulation/legislation to allow physicians to be paid by health insurers for referrals and prior authorizations reflecting their costs in time and personnel for each and every referral or prior authorization sought.  (HOD 2008-53; Reaffirmed HOD 2018; Reaffirmed HOD 2023-106)

265.903           Complexity of the RBRVS Evaluation and Management Codes: (HOD 2008-257; SUNSET HOD 2018)

265.904           Reduced Hassle for the Hassle Factor Form: (HOD 2008-255’ SUNSET HOD 2018)

265.905           Availability of Cornea Donor Tissue:  (HOD 2008-167; SUNSET HOD 2018)

265.906           Physician Reimbursement for Home Care:  (HOD 2008-161; SUNSET HOD 2018)

265.907           Promotion of the Hassle Factor Form:  (Council 3/3/08; SUNSET HOD 2018)

265.908           Impediments Imposed by Health Insurance Companies to Obtaining Pre-Authorization:

MSSNY will take appropriate steps including, if necessary, seeking the enactment of legislation and regulation, to eliminate unnecessary impediments imposed by health insurance companies to obtaining pre-authorization, including reducing the need and time for obtaining pre-authorizations.  (Council 3/3/08; Reaffirmed HOD 2008-50; Reaffirmed HOD 2016-262)

265.909           HMOs Decreasing Reimbursement & Patient Co-Payments:

MSSNY will continue to advocate to the Legislature, the Governor, the Department of Health and other relevant policymakers to address the problem facing physicians, businesses and patients regarding inappropriately constrained provider reimbursement, rapidly increasing health insurance premiums and increased patient cost-sharing at the same time that health plans are generating enormous and excessive profits.  (Council 3/3/08; Reaffirmed HOD 2018)

265.910           Publicizing the Hassle Factor Form:

Deleted (HOD 2007-264, Combined with 265.915 as single policy, HOD 2017)

265.911           ERISA Plans and the United States Department of Labor:

MSSNY will seek the support of the American Medical Association in proposing an amendment to federal legislation that would modify ERISA law to incorporate a clause that addresses timely payment of medical claims of health care practitioners who provide treatment in good faith to the members of self-funded group employer-sponsored health plans; and

When the federal law is amended, the Medical Society of the State of New York will work with the United States Department of Labor to devise and implement a formalized appeal process at the United States Department of Labor, with a specific dedicated service center and contact persons.  (HOD 2007-251; Reaffirmed HOD 2017)

265.912           Reimbursement for Participation:

MSSNY adopts the American Medical Association’s Principles for Pay-for-Performance and Guidelines for Pay-for-Performance, H-450.947: 

PRINCIPLES FOR PAY-FOR-PERFORMANCE PROGRAMS

Physician pay-for-performance (PFP) programs that are designed primarily to improve the effectiveness and safety of patient care may serve as a positive force in our health care system. Fair and ethical PFP programs are patient-centered and link evidence-based performance measures to financial incentives.  Such PFP programs are in alignment with the following five AMA principles:

1. Ensure quality of care – Fair and ethical PFP programs are committed to improved patient care as their most important mission. Evidence-based quality of care measures, created by physicians across appropriate specialties are the measures used in the programs. Variations in an individual patient care regimen are permitted based on a physician’s sound clinical judgment and should not adversely affect PFP program rewards.  2. Foster the patient/physician relationship – Fair and ethical PFP programs support the patient/physician relationship and overcome obstacles to physicians treating patients, regardless of patients’ health conditions, ethnicity, economic circumstances, demographics, or treatment compliance patterns.
2. Offer voluntary physician participation – Fair and ethical PFP programs offer voluntary physician participation, and do not undermine the economic viability of non-participating physician practices. These programs support participation by physicians in all practice settings by minimizing potential financial and technological barriers including costs of start-up.
3. Use accurate data and fair reporting – Fair and ethical PFP programs use accurate data and scientifically valid analytical methods. Physicians are allowed to review, comment and appeal results prior to the use of the results for programmatic reasons and any type of reporting.
4. Provide fair and equitable program incentives – Fair and ethical PFP programs provide new funds for positive incentives to physicians for their participation, progressive quality improvement, or attainment of goals within the program. The eligibility criteria for the incentives are fully explained to participating physicians. These programs support the goal of quality improvement across all participating physicians. 

GUIDELINES FOR PAY-FOR-PERFORMANCE PROGRAMS

Safe, effective, and affordable health care for all Americans is the AMA’s goal for our health care delivery system.  The AMA presents the following guidelines regarding the formation and implementation of fair and ethical pay-for-performance (PFP) programs.  These guidelines augment the AMA’s “Principles for Pay-for-Performance Programs” and provide AMA leaders, staff and members with operational boundaries that can be used in an assessment of specific PFP programs.

Quality of Care

– The primary goal of any PFP program must be to promote quality patient care that is safe and effective across the health care delivery system, rather than to achieve monetary savings.

– Evidence-based quality of care measures must be the primary measures used in any program.

1. All performance measures used in the program must be prospectively defined and developed collaboratively across physician specialties.
2. Practicing physicians with expertise in the area of care in question must be integrally involved in the design, implementation, and evaluation of any program.
3. All performance measures must be developed and maintained by appropriate professional organizations that periodically review and update these measures with evidence-based information in a process open to the medical profession.
4. Performance measures should be scored against both absolute values and relative improvement in those values.
5. Performance measures must be subject to the best-available risk- adjustment for patient demographics, severity of illness, and co-morbidities.
6. Performance measures must be kept current and reflect changes in clinical practice. Except for evidence-based updates, program measures must be stable for two years.
7. Performance measures must be selected for clinical areas that have significant promise for improvement.

– Physician adherence to PFP program requirements must conform with improved patient care quality and safety.

– Programs should allow for variance from specific performance measures that are in conflict with sound clinical judgment and, in so doing, require minimal, but appropriate, documentation.

– PFP programs must be able to demonstrate improved quality patient care that is safer and more effective as the result of program implementation.

– PFP programs help to ensure quality by encouraging collaborative efforts across all members of the health care team.

– Prior to implementation, pay-for-performance programs must be successfully pilot-tested for a sufficient duration to obtain valid data in a variety of practice settings and across all affected medical specialties. Pilot testing should also analyze for patient de-selection. If implemented, the program must be phased-in over an appropriate period of time to enable participation by any willing physician in affected specialties.

– Plans that sponsor PFP programs must prospectively explain these programs to the patients and communities covered by them.

Patient/Physician Relationship

– Programs must be designed to support the patient/physician relationship and recognize that physicians are ethically required to use sound medical judgment, holding the best interests of the patient as paramount.

– Programs must not create conditions that limit access to improved care.

1. Programs must not directly or indirectly disadvantage patients from ethnic, cultural, and socio-economic groups, as well as those with specific medical conditions, or the physicians who serve these patients.
2. Programs must neither directly nor indirectly disadvantage patients and their physicians, based on the setting where care is delivered or the location of populations served (such as inner city or rural areas).

– Programs must neither directly nor indirectly encourage patient de-selection.

– Programs must recognize outcome limitations caused by patient non-adherence, and sponsors of PFP programs should attempt to minimize non-adherence through plan design.

Physician Participation

– Physician participation in any PFP program must be completely voluntary.

– Sponsors of PFP programs must notify physicians of PFP program implementation and offer physicians the opportunity to opt in or out of the PFP program without affecting the existing or offered contract provisions from the sponsoring health plan or employer.

– Programs must be designed so that physician nonparticipation does not threaten the economic viability of physician practices.

– Programs should be available to any physicians and specialties who wish to participate and must not favor one specialty over another.  Programs must be designed to encourage broad physician participation across all modes of practice.

– Programs must not favor physician practices by size (large, small, or solo) or by capabilities in information technology (IT).

1. Programs should provide physicians with tools to facilitate participation.
2. Programs should be designed to minimize financial and technological barriers to physician participation.

– Although some IT systems and software may facilitate improved patient management, programs must avoid implementation plans that require physician practices to purchase health-plan specific IT capabilities.

– Physician participation in a particular PFP program must not be linked to participation in other health plan or government programs.

– Programs must educate physicians about the potential risks and rewards inherent in program participation, and immediately notify participating physicians of newly identified risks and rewards.

– Physician participants must be notified in writing about any changes in program requirements and evaluation methods. Such changes must occur at most on an annual basis.

Physician Data and Reporting

– Patient privacy must be protected in all data collection, analysis, and reporting. Data collection must be administratively simple and consistent with the Health Insurance Portability and Accountability Act (HIPAA).

– The quality of data collection and analysis must be scientifically valid. Collecting and reporting of data must be reliable and easy for physicians and should not create financial or other burdens on physicians and/or their practices. Audit systems should be designed to ensure the accuracy of data in a non-punitive manner.

1. Programs should use accurate administrative data and data abstracted from medical records.
2. Medical record data should be collected in a manner that is not burdensome and disruptive to physician practices.
3. Program results must be based on data collected over a significant period of time and relate care delivered (numerator) to a statistically valid population of patients in the denominator.

– Physicians must be reimbursed for any added administrative costs incurred as a result of collecting and reporting data to the program.

– Physicians should be assessed in groups and/or across health care systems, rather than individually, when feasible.

– Physicians must have the ability to review and comment on data and analysis used to construct any performance ratings prior to the use of such ratings to determine physician payment or for public reporting.  1. Physicians must be able to see preliminary ratings and be given the opportunity to adjust practice patterns over a reasonable period of time to more closely meet quality objectives.  2. Prior to release of any physician ratings, programs must have a mechanism for physicians to see and appeal their ratings in writing. If requested by the physician, physician comments must be included adjacent to any ratings.

– If PFP programs identify physicians with exceptional performance in providing effective and safe patient care, the reasons for such performance should be shared with physician program participants and widely promulgated.

– The results of PFP programs must not be used against physicians in health plan credentialing, licensure, and certification. Individual physician quality performance information and data must remain confidential and not subject to discovery in legal or other proceedings.

– PFP programs must have defined security measures to prevent the unauthorized release of physician ratings.

Program Rewards

– Programs must be based on rewards and not on penalties.

– Program incentives must be sufficient in scope to cover any additional work and practice expense incurred by physicians as a result of program participation.

– Programs must offer financial support to physician practices that implement IT systems or software that interact with aspects of the PFP program.

– Programs must finance bonus payments based on specified performance measures with supplemental funds.

– Programs must reward all physicians who actively participate in the program and who achieve pre-specified absolute program goals or demonstrate pre-specified relative improvement toward program goals.

– Programs must not reward physicians based on ranking compared with other physicians in the program.

– Programs must provide to all eligible physicians and practices a complete explanation of all program facets, to include the methods and performance measures used to determine incentive eligibility and incentive amounts, prior to program implementation.

– Programs must not financially penalize physicians based on factors outside of the physician’s control.

– Programs utilizing bonus payments must be designed to protect patient access and must not financially disadvantage physicians who serve minority or uninsured patients.

(2) Our AMA opposes private payer, Congressional, or Centers for Medicare and Medicaid Services pay-for-performance initiatives if they do not meet the AMA’s “Principles and Guidelines for Pay-for-Performance.” (BOT Rep. 5, A-05; Reaffirmation A-06; Reaffirmed: Res. 210, A-06; Reaffirmed in lieu of Res. 215, A-06; Reaffirmed in lieu of Res. 226, A-06; Reaffirmation I-06; Reaffirmation A-07).  (HOD 2007-94; Modified and Reaffirmed HOD 2017) 

265.913           Managed Care and Medicare “Carve-Out” Services: 

In those instances where an insurance company has “carved out” specific services, and has contracted with an outside party to arrange and pay for these services, and then denies reimbursement on the basis that such payment is no longer their responsibility, MSSNY to (1) advocate for a physician’s ability to seek payment directly from the patient without being considered a violation of the physician’s participation agreement; and (2) seek legislation, regulation or other appropriate means to assure that participating physicians and patients are given advance written notification by payors that the plan has carved out the provision of and payment for specific services such as radiology or diagnostic studies to a specific third party.  (HOD 2007-66; Reaffirmed HOD 2017)

265.914           Electronic Payment or Funds Transfer Systems:

MSSNY will:  (1) urge insurance companies initiating electronic payment or funds transfer systems to allow physicians with fewer than 10 Full-Time Equivalent (FTE) Employees to claim an exemption to mandatory electronic payment or funds transfer system; (2) seek to assure that physician practices of all sizes have the option to receive payments electronically; and (3) work with appropriate regulatory agencies to assure that health insurers may not withdraw funds from a physician’s account, except with the express written authorization of the physician.  (HOD 2007-63; Reaffirmed HOD 2017)

265.915           Insurance Companies and Publicizing the Hassle Factor Form:

That MSSNY monitor unfair business practices of health plans through the use of the new MSSNY Hassle Factor Form (HFF), creating or joining with a coalition of stakeholders (to include physician groups and leaders of industry and business who bear the burden of health care costs) and dependent upon the anticipated reports culminating from the use of the HFF and the work of the coalition seek passage of state regulation and/or legislation to rectify these unfair business practices.  MSSNY will take whatever steps it can to maximize use of the Hassle Factor form and disseminate its findings to all concerned.   (HOD 2006-269; Reaffirmed Council 12/13/07; 265.915 Amended by inclusion of 265.910 and Reaffirmed HOD 2017)  (265.910 -HOD 2007-264) deleted and combined with 265.915 HOD 2017)

265.916           NYS DOH Review of Provider Contracts:

That MSSNY seek legislation, regulation or other appropriate means to assure that the Department of Health review health plan standard provider contracts to assure that the contract terms contained are fair to physicians and patients in those situations where the health plan holds a 10% market share in a particular region of the State; and to assure that the Commissioner of Health or the Superintendent of Insurance organize roundtable meetings between health insurance companies and physician representatives for the specific purpose of discussing and attempting to resolve problematic contract terms in standard health plan contracts.  (HOD 2006-65; Reaffirmed HOD 2016)

265.917           Pay for Performance:

MSSNY recommend that all Pay for Performance (PFP) programs pay physicians a per-member-per-month fee for data collection for all lives covered in the program; that this policy be consistently articulated by all MSSNY representatives at any meeting regarding PFP; that MSSNY neither endorse any PFP programs nor encourage its members to participate in any PFP programs unless all participating physicians receive adequate compensation for data collection and submission; and that a similar resolution be sent to the American Medical Association.  (HOD 2006-93; Reaffirmed HOD 2016)

265.918           Payment for Urgent and Emergent Health Care Services:

That MSSNY seek public policy, regulation or legislation that would require health care payers in New York to pay for all reasonable urgent and emergent medical services for their covered patients, that the definition of reasonable urgent medical services should carry the prudent layperson standard similar to what is already in effect for emergent medical services, and that health care payers reimburse out of network physicians for care provided on urgent or emergency basis at a level which the physician believes fairly reflects the costs of providing a service and the value of their professional judgment.  (Council 1/26/06; Reaffirmed HOD 2017; Reaffirmed HOD 2018-57)

265.919           Hassle Factor: 

MSSNY embark on the production and implementation of an electronic data collection program of insurance grievances; and create a mechanism to enable access for those members who are not electronically connected. (Council 1/26/06; Reaffirmed HOD 2016)

265.920           Payments for Urgent and Emergent Health Care Services:  Sunset HOD 2017

265.921           Unreasonable Taxes on Medical Care:

MSSNY proactively and vigorously opposes taxes on physician services including but not limited to cosmetic surgery, physician-owned facility taxes or “pass-through” taxes on medical services.  (HOD 2005-88; Reaffirmed HOD 2010-68; Reaffirmed HOD 2020)

265.922          Supporting Legislation to Promote Telemedicine: HOD 2005-53; SUNSET HOD 2015)

265.923           Legal Strategies to Combat Unsubstantiated Third-Party Payer Refund Demands: 

MSSNY will continue to monitor refund demands stemming from carrier errors that appear to demonstrate unfair business practices that are deceptive, misleading or fraudulent and report these to the Office of the Attorney General. (HOD 2005-214; Reaffirmed HOD 2015)

265.924           Gross Receipts Tax: 

MSSNY oppose the imposition of taxes and cuts in payment that hinder the ability of physicians to provide needed care to patients. (HOD 2004-81; Reaffirmed HOD 2014)

• Pay Physicians for Emergency Room Call:

MSSNY urges hospitals to compensate physicians for being “on emergency room call” unless they choose to work voluntarily.  (Council 6/3/04; Reaffirmed HOD 2014)

• Single Set of Rules for Physician Reimbursement: SUNSET HOD 2014 ( Reaffirmed HOD 2024)

265.927            Patients’ Out of Pocket Financial Responsibility for Emergency Room Services Provided: SUNSET HOD 2024

265.928           Preventive Healthcare Reimbursement: SUNSET HOD 2014

265.929           Elimination of Pre-Surgical Authorizations: SUNSET HOD 2013

265.930           Reimbursement for Well Child Visits: SUNSET HOD 2013

265.931           Out-of-Network Status Should be Applied Only to Specifically Out-of-Network Providers:

MSSNY will seek legislation that would prevent health insurance plans from refusing reimbursement to participating members of a medical team involved in the care of a patient when there is a non-participating member of the team involved in the patient’s care.  Non-participating status would apply only to the non-participating provider.  (HOD 2002-264; Modified and reaffirmed HOD 2013; Reaffirmed HOD 2023)

265.932           Amendment to the Definition of “Covered Service” for Third Party Insurance Payment:

MSSNY has adopted as policy the following definition of covered service for insurance payment purposes.  A covered service is defined as:  (l) separately identifiable by the American Medical Association Current Procedural Terminology code; (2) allowed, reimbursable, and paid by the third party insurer or plan; and (3) therefore, all other services be considered non-covered and be considered the responsibility of the plan subscriber.

MSSNY will seek legislation incorporating this definition in future legislative actions.(HOD 2002-261; Reaffirmed HOD 2003-268 & 278; Reaffirmed HOD 2013; Reaffirmed HOD 2023)

265.933           Automatic Crossover of Payment between Medicare and Medicaid:  SUNSET HOD 2019

265.934           Reduction of Surgical Aftercare Periods:

MSSNY will advocate for a maximum aftercare period of 30 days for reimbursement related to each surgical procedure. (HOD 2002-251; Reaffirmed HOD 2013; Reaffirmed HOD 2023)

265.935           Third Party Payors Held to the Same Standard of Payment:

MSSNY will seek legislation or whatever appropriate means are necessary to assure that third party payors are held to the standard of the Prompt Payment Law and that the provider should have the ability to collect payment from the patient if the claim is denied for reasons not due to the fault of the physician.  (HOD 2002-80; Reaffirmed HOD 2003-268 & 278; Reaffirmed HOD 2013; Reaffirmed HOD 2023)

265.936           Support the Health Insurance Guarantee Fund: SUNSET HOD 2013

265.937           Changing of Prescriptions by Managed Care Organizations or Pharmacies:

MSSNY will seek regulation and/or legislation to mandate that health insurers recognize and reimburse for existing CPT codes for patient management activities when the insurer and/or PBM request the substitution of a prescription drug for that which has been prescribed.  (HOD 2002-51; Reaffirmed HOD 2013; Reaffirmed HOD 2015-56)

265.938           Contact Information Needed on EOMBs:

It is MSSNY’s policy that the New York State Department of Financial Services should impose a new requirement on all third-party payers, requiring that these plans format their Explanation of Medical Benefits (EOMBs) to include the name and phone number of a responsible, readily available individual on the carrier staff.

MSSNY will urge the New York State Department of Financial Services to require all third party payers to respond to telephone inquiries within twenty-four hours. (HOD 2001-260; Reaffirmed HOD 2009-259; Reaffirmed HOD 2019)

265.939           Electronic Billing: SUNSET HOD 2013

265.940           Aetna/US HealthCare’s Use of a Primary Physician Communication Form: Sunset HOD 2011

265.941        Addressing  Third Party Payers’ Policy Regarding Modifier 25:

MSSNY will recommend that all third party payers pay for Modifier 25 submitted by physician practices.  (Council 1/25/01; Reaffirmed HOD 2003-268 & 278; Modified and reaffirmed HOD 2013; Reaffirmed HOD 2023)

265.942           Costs to the Private Medical Practitioner of Complying with New Unfunded Federal Mandate Called the Needlestick Safety and Prevention Act: Sunset HOD 2011

265.943           Coverage of Strabismus Surgery: Sunset HOD 2011

265.944           Multiple Billing Addresses for Submission of Doctors’ Bills to Individual Health Care Plans:
Sunset HOD 2011

265.945           Prevnar, Pneumococcal 7-Valent Conjugate Vaccine: Sunset HOD 2011

265.946           Adequate Reimbursement for Screening Mammography:

MSSNY will seek regulation and/or legislation that ensures payment for diagnostic and screening mammography at a rate commensurate with the cost of services.  (HOD 2001-254; Reaffirmed HOD 2013; Reaffirmed HOD 2023)

265.947           Autism:

MSSNY will seek the passage of state and federal legislation requiring the insurance industry to cover scientifically-proven, effective therapy services needed by autistic individuals.  (HOD 2001-167; Reaffirmed HOD 2003-276; Reaffirmed HOD 2015)

265.948           Vaccination Schedule Should be Accepted by All Insurance Carriers:   SUNSET HOD 2014

265.949           Periodic Summary of Physician Submitted Claims

MSSNY will seek legislation, regulation or other appropriate action that would require all insurance companies and managed care plans licensed in the State of New York to provide each physician who has submitted a claim to that company or plan with a periodic summary (weekly, monthly or quarterly) of all of that physician’s pending claims, including the status of each claim, regardless of the physician’s participation status with that company or the manner by which the claim has been submitted, i.e. paper or electronic format. (HOD 2001-83; Reaffirmed HOD 2011; Reaffirmed HOD 2021)

265.950           Insurance Company/Managed Care Plan Acceptance of Physicians Submitted Claims: Sunset HOD 2011

265.951           Cost of Living Adjustment to Compensate for Rising Overhead Medical Expenses

MSSNY supported a resolution to the American Medical Association House of Delegates requesting passage of federal legislation requiring that insurance reimbursement have an annual cost of living adjustment to compensate for rising overhead expenses.  (HOD 2001-58; Reaffirmed HOD 2011; Reaffirmed HOD 2021)

265.952           HCFA Evaluation and Management Codes – Modifier 25:  SUNSET HOD 2014

265.953           Reimbursement for Baclofen Pump: SUNSET HOD 2024

265.954           Implementation of Carrier Advisory Committee (CAC) Functions by Third-Party Insurers:

MSSNY will seek legislative or regulatory relief to require all third-party payers to implement a Carrier Advisory Committee (CAC) function, in order that carriers’ medical/surgical claims processing policies may be codified with the input of the specialty societies in New York State.  (HOD 2000-269; Reaffirmed HOD 2003-268 & 278; Reaffirmed HOD 2013; Reaffirmed HOD 2023)

265.955           Managed Care Organizations Should Disclose Their UCR Calculation Methodology: SUNSET HOD 2014

265.956           Unfair Claims Filing by HMOs:

MSSNY will seek legislative action to prevent any Third Party Payer doing business in New York State from seeking repayment or refund through withholding of claim payments relating to treatment of other patients (offset).  (HOD 2000-265; Reaffirmed HOD 2010-259; Reaffirmed HOD 2020)

265.957           Recognition of “Incident To” Services: SUNSET HOD 2013

265.958           Authorized Assignment of Benefits:

MSSNY will seek legislation or regulation to: (a) ensure that third-party payers be required to issue payment directly to providers when the patient has signed an authorization for the assignment of benefits; (b) mandate that health plans notify physicians when claim payments are issued to the insured rather than the physician who has an assignment agreement; (c) develop a mechanism for health plans to have the legal responsibility for reporting claim payments made to insureds/patients to the Internal Revenue Service as ‘1099’ Compensation Income when payment has not been made to the physician who provided care.

MSSNY will seek federal legislation to have plans currently protected by ERISA produce the same ‘1099’ Compensation Income reports made to the beneficiary when health plan payments are made to the beneficiary rather than the physician who provided treatment.  (HOD 2000-256; Reaffirmed HOD 2009-63; Reaffirmed HOD 2015 in lieu of res 63; Reaffirmed HOD-2016-50)

265.959           Insurance Companies Should Reimburse Physicians for Telephone Time with Pharmacies:

MSSNY will seek regulatory or legislative action to (a) require health care plans doing business in New York State to recognize, as a separate service, through the existing AMA-CPT coding nomenclature, telephone calls communicating with family members, medical entities, pharmacies, benefit management companies, case managers, and others as required for patient management and care; (b) require health care plans in New York State to disclose in the health plan’s benefit package that telephone management services for patients, as well as the time spent placing the phone call(s) is a separate service and specify whether the service is a covered or non-covered service.

If telephone management for patients, and the time spent making the phone call(s) is deemed to be a non-covered service, MSSNY will seek regulatory or legislative relief which would require health care plans to honor an Advance Notification Agreement between the physician and the patient through a formal Waiver of Liability, whereby payment for this service becomes the responsibility of the patient.

MSSNY will seek regulatory or legislative action mandating the provision of toll-free telephone and FAX numbers for physician use by all health care plans, products and mail order pharmacies doing business in New York State.  Said legislation or regulation will include a provision that the waiting time for physicians and their office staff required by the payers to use these toll-free telephone numbers be no more than five (5) to ten (10) minutes.  (HOD 2000-252; Reaffirmed 2014 HOD; Reaffirmed HOD 2015-56)

265.960           Reimbursement of Accutane: SUNSET HOD 2024

265.961           Accountability of Management  Service Organizations:

MSSNY will seek legislation which would (a) require that management service organizations that contract with health insurance entities to review, process and pay physician-submitted claims, grant authorizations and pre-certifications where appropriate, apply internal policy payment parameters frequently without physician input, be held accountable to the same State imposed standards, i.e. the Prompt Payment Law, as all insurance entities licensed in New York State, (b) mandate that the New York State Insurance Department have jurisdiction over management service organizations which contract with health insurance entities to review, process and pay claims.

It is MSSNY policy that insurance entities licensed in New York State that contract with management service organizations should be held accountable for the actions of these contracted organizations.  (HOD 2000-88; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

265.962           Enhancements to the Prompt Payment Law

MSSNY will seek enhancements to the current Prompt Payment Law stipulating that when additional information has been requested and received from a physician and/or patient, that the health care plan requesting the information be required to process and pay that claim within a specified (reasonable) period of time, or be subject to severe monetary penalties.

Once an HMO places a claim in a “pended” category (awaiting additional information), the HMO should be required to continue written communications with the physician and/or patient, on a periodic basis (i.e., every 30, 60 or 90 days) until the requested documentation has been received. (HOD 2000-71; Reaffirmed HOD 2014; Reaffirmed HOD 2021-56)

265.963           All Products Clause in Insurance Participating Provider Contracts:

MSSNY will seek legislation to ban “all products” clauses in health care plan participating provider contracts, and to bar health care plans from requiring participation in any other products as a requisite for participation in Child Health Plus or Family Health Plus.  (HOD 2000-68; Reaffirmed HOD 2014; Reaffirmed HOD 2016-52)

265.964           Review of Pre-Authorizations by a Licensed Physician:

MSSNY will seek legislation to require that all pre-authorizations for procedures be reviewed by a New York State licensed practicing physician who is board certified or board eligible in the same specialty as the requesting physician prior to any denial of pre-authorization.  (HOD 2000-67; Reaffirmed HOD 2014; Reaffirmed HOD 2023-106)

265.965           Physician Appeal’s Mechanisms for Down Coded or Denied Claims:

MSSNY will seek legislation and/or regulation to ensure that physicians have an appropriate appeals mechanism which third party payors should make available to physicians when claims have been denied or “down coded” by such payors.  Such legislation and/or regulation should require (a) all payors to notify the physicians of the appropriate appeals mechanism to be utilized when a claim is denied or “down coded” and (b) all third party payors to provide physicians with a clear and accurate explanation on all claims that have been denied or “down coded”.  (HOD 2000-66; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

265.966           Circumvention of the Prompt Payment Law in New York State:

MSSNY will seek amendment to the present Prompt Payment legislation to impose penalties on those carriers that have been determined to be circumventing the Prompt Payment law by “forcing claims to payment” to meet the prescribed deadlines and then demanding refunds well after the claims have been paid.  (HOD 2000-65; Reaffirmed HOD 2104; Reaffirmed HOD 2024)

265.967           Recognition of Modifier 25: SUNSET HOD 2014

265.968           Pre-Authorization Denials: SUNSET HOD 2014

265.969           Proper Insurance Claim Protocol: SUNSET HOD 2013

265.970           Prompt Payment Law:

MSSNY will seek legislation to amend the Prompt Payment Law so as to allow relief for physicians through a class action suit. (Council 9/30/99; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

265.971           Guaranteed Trust Corporation for Health Insurance:

MSSNY will seek legislation or regulation requiring the information of a Guaranteed Trust Corporation for health insurance in New York State.  (Council 2/4/99; Reaffirmed HOD 2014)

265.972           Responsibility for Carrier Errors on “Explanation of Benefits Forms:  SUNSET HOD 2014

265.973           Physician Responsibility for County Nursing Service:

MSSNY will seek federal and state legislative or regulatory relief requiring Medicare and other insurers based in this state to hold Nursing Service Agencies responsible for their billing practices and for the care decisions they make that either deviate from physician instructions, are devoid of related physician input, or are violative of HCFA guidelines.  Physicians will be held harmless when their Home Health Certification and Plan of Care Forms (HCFA 485 form) differ from by the actual services rendered by the Nursing agencies, and MSSNY shall pursue every available avenue at both the state level and nationally through our representation with the American Medical Association to protect physicians from being held responsible for care provision and billing beyond their control pertaining to Nursing services.  (HOD 1999-273; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

265.974           Support of MSSNY President Ralph Schlossman’s Response to HCFA’s “Fraud Seminars: SUNSET HOD 2014

265.975           Inappropriate Usage Of Correct Coding Initiative and HBOC Software By Medicare:

MSSNY will oppose the reduction of payment for medical services under Medicare without notice or the publication of regulations, including the continuing expansion of the Correct Coding Initiative (CCI) in concert with the “Black Box” edits produced by HBOC Software.  MSSNY will communicate its objection to the reduction of payments for services by the continuous expansion of the CCI in conjunction with HBOC Software directly to HCFA and through its representatives on the New York Medicare Carrier Advisory Committee and the American Medical Association.  MSSNY will instruct its Delegates to the American Medical Association House of Delegates to introduce a resolution at its next meeting asking the AMA to take all necessary steps to prevent the continuation of the reduction in payments or medical services under Medicare by inappropriate usage of the CCI and the HBOC Software or any equivalent process without notice to or comment by the public or Medical profession.  (HOD 1999-256; Reaffirmed HOD 2000-268; HOD 2003-268 & 278 and HOD 2005-276; Reaffirmed HOD 2015)

265.976           Cost of Living Increases to Physician:

MSSNY will seek the introduction of appropriate state legislation calling for the levels of physician payments by public and private health insurers to be annually adjusted with a cost of living increase tied to the Department of Labor cost of living index, with this increase remaining independent of adjustments made for any rising costs of providing services.  (HOD 1999-255; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

265.977           Pre-authorization/Certification Binding Primary and Secondary Payers:

MSSNY will initiate legislative or regulatory efforts to enable the pre-certification of the primary insurance company to be binding on all secondary payers regardless of whether Coordination of Benefits or other supplementary medigap-type coverage is involved.  If there is no Pre-Certification required by primary insurers, then secondary payers must honor their financial obligations. (HOD 1999-261; Reaffirmed HOD 06-259; Reaffirmed HOD 2016)

265.978           Reimbursement for Assistance at  Surgery: SUNSET HOD 2014

265.979           Insurance Companies Should Reimburse for Telephone Consultations: 

MSSNY policy should be that insurance companies and the Health Care Financing Administration should reimburse physicians for telephone management of patients.  (HOD 1999-258; Reaffirmed HOD 2005-273; Reaffirmed HOD 2015)

265.980           Enhancements to HMO Prompt Payment: 

MSSNY will petition the Governor of the State of New York to modify the current Prompt Payment Law to provide for the imposition of a penalty of up to 20% of the amount billed, payable directly to the physician by the payor, for any clean claim not paid within the 45-day time frame.  The Prompt Payment Law should also be modified to include payment to the physician of punitive damages for clean claims not processed or paid within 45 days when it can be shown that an intentional “pattern of abuse” exists on the part of the HMO, ERISA plan, or insurance company.  When an intentional pattern of abuse is found to be exhibited by an HMO, ERISA plan, or insurance company in not paying physicians’ claims within the prescribed 45-day limit, that the HMO’s license be subject to suspension or revocation.  The Prompt Payment Law be further amended to reflect that in the event suspension or revocation of license is not forthcoming, that the New York State Insurance Department be granted the legislative authority to mandate that these efficient HMO, ERISA plan, or insurance companies be required to increase their monetary reserves by 25%, and that managed care plans be required to provide written proof of “unclean claims.”  (HOD 1999-72; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

265.981           ERISA Plans Should be Held Accountable to the Same Reimbursement Requirements as other Insurance Carriers in the 1997 Prompt Payment Legislation: 

The Medical Society of the State of New York supports legislation that would require ERISA plans to pay medical insurance claims in a timely manner as other insurance carriers in New York State are required to do.  (HOD 1998-87; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

265.982           Reimbursement Moratorium on Merged Health Maintenance Organizations:

MSSNY will seek appropriate legislation which, in the event of a merger or consolidation of one or more health maintenance organizations, would impose a one-year moratorium after the announcement of a new fee schedule, thereby precluding the lowering of reimbursement to participating physicians for this one-year period. (HOD 1998-273; Reaffirmed HOD 2014)

265.983           The Prudent Physician Paradigm:

It is MSSNY’s position that if a physician excises a clinically suspicious skin lesion, the insurer should be held liable for payment for the surgical procedure regardless of the subsequent pathology report.

MSSNY will request legislative or regulatory action that when a physician performs an indicated procedure based on a presumptive diagnosis, the third party payer reimburse the physician performing the procedure regardless of the final diagnosis.  (HOD 1998-271; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

265.984           Amend Managed Care Payment Policy for X-Ray Examinations: SUNSET HOD 2014

265.985           Third Party Fee Schedule:

MSSNY will seek legislation at both state levels and national levels that would mandate insurers to make available their complete fee schedules, coding policies, and utilization review protocols to physicians prior to signing a participant contract and whenever any changes are made to the foregoing.  (HOD 1998-262; Reaffirmed HOD 2014; Reaffirmed HOD 2016-56)

265.986           Physician Due Process in Managed Care:

Should a physician participant in one plan of an Insurance Company be denied access to other newly evolved plans that Insurance Company offers, the reason for such must be provided in writing and an appeals process be established to review that decision in a timely fashion. (Council 12/18/97; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

265.987           AMA-CPT Coding

MSSNY endorses AMA-CPT as the standard accepted coding system in New York and that proper use of CPT by insurance carriers requires adherence to all of its rules and guidelines; and will recommend that the Insurance Superintendent and the New York State Legislature require health insurance carriers processing claims from New York physicians, including Workers’ Compensation and No-Fault Carriers, to adhere to all CPT rules and guidelines, including code modifiers.  MSSNY will request that the Insurance Superintendent make the necessary revisions of the inappropriate bundling edits in the software which erroneously processes claims from physicians and disallows legitimate claims for services.  (HOD 1997-285; Reaffirmed HOD 2000-251, HOD 2000-257, HOD 2000-268, HOD 2003-268 & 278 and HOD 2005-254 & 276; Reaffirmed HOD 2013; Reaffirmed HOD 2021-252)

265.988           Payment Of Balance Of Bills By Secondary Health Insurance Agencies:

MSSNY will seek legislative reform in the New York State Insurance Law that would: (a)  require all health insurance plans licensed in this state to include a Coordination of Benefits (COB) clause in their contracts clearly delineating their responsibilities as secondary insurers;  (b)  require that when a dually covered person complies with the provisions of a primary health insurance Plan by obtaining treatment from a participating physician, the secondary plan (by virtue of premiums paid for its coverage) must honor the liability for payment of deductible, coinsurance, co-payment and/or balance payment amounts (up to the highest payment level of the two insurance plans) regardless of the treating physician’s participation status with the secondary insurer;  (c)  require all health insurance plans licensed in this state to provide full and clear disclosure about a Plan’s secondary liability to its insured and its contracted physicians at the time of enrollment; and  (d)  require the New York State Department of Financial Services to review health insurers’ reports concerning savings they have accrued in their roles as secondary payers and to pass on these savings to consumers in the form of reduced premiums. (HOD 1997-279; Reaffirmed HOD 2000-264 & HOD 2006-259; Amended HOD 2016)

265.989           Changes In Reimbursement Rates And Payment Of Benefits Policies Of Insurance Carriers Without Recourse By Participating Physicians:

MSSNY will actively seek, through legislation or whatever regulatory means necessary, the establishment of a mechanism whereby HMOs and other health insurers licensed in the State of New York be required to: (a)  include in their annual financial reports to the Superintendent of Insurance any proposed changes in reimbursement schedules and withholds for physicians participation in their plans;  (b) include in their participating physician agreements an anniversary date indicating the duration that the contracted fees, withholds, and payment policies will remain in effect.  (HOD 1997-270; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

265.990           Denial of Claims: 

MSSNY will seek to have legislation introduced that will require carriers to send a copy of their examiner’s report to the treating physician with a provision that the denial cannot be issued until seven working days have passed from the time the report is mailed to the treating physician.  (HOD 1997-263; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

265.991           Physicians Should Be Informed By the Third Party Payor of the Reason for the Denial of the Claim:

MSSNY will seek the appropriate legislative or regulatory means to require that all third party payors, licensed to operate in New York State, be required to provide in a timely manner to the physicians with a rejected claim notice with an indication of the reason and the codes indicating why the claim was rejected.  (HOD 1997-260; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

265.992           Reimbursement of Alternative Therapies By HMOs:

MSSNY will support legislative action to prevent insurance coverage by managed care companies for unproven alternative therapies and unlicensed practitioners.  (HOD 1997-163; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

265.993           Denial of Payments, “No Fault” Insurance Carriers: SUNSET HOD 2014; See 265.998

265.994           Determination of Where Medically Necessary Services  Are to be Provided to Patients Enrolled in Managed Care Entities: 

MSSNY has adopted the position that in the event that a patient enrolled in a managed care program is referred to the emergency room of a local hospital following direct or verbal contact with a participating physician, this visit be covered and reimbursable whether categorized as emergent or not.  (HOD 1994-262; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

265.995           Balance Billing – Benefits in Health System Reform:

MSSNY supports the position that the practice of Balance Billing is in the best interest of:  (1)  Patients who will assume personal responsibility for a portion of their health care cost, and  (2)  Physicians and other providers who will be able to bill for an appropriate fee, yet still be subject to being monitored for such billing, and  (3)  Payers, government or other, who will have reduced financial liability, thus reducing the cost to third party payers.

MSSNY endorses the position that health system reform proposals include a provision that patients be free to contract with physicians of their choice to obtain medical services regardless of the insurance reimbursement.  (HOD 1994-218; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

265.996           Reimbursement Based on Outcome:  SUNSET HOD 2014

265.997           Benefits Denial by HMOs and Third Party Carriers:  SUNSET HOD 2013

265.998           “No Fault” Accident Victims: MSSNY continues to support legislation and all other means to amend the “no fault law” to ensure that physicians and hospitals are paid regardless of the involvement of alcohol as possible cause of the accident which resulted in the injury being treated.  (HOD 1992-34; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

265.999           Third Party Reimbursement Mechanism: 

MSSNY recognizes the validity of a pluralistic approach to third party reimbursement methodology and that indemnity, as well as UCR, have positive aspects which merit further study.  It will continue its analysis of the merits of indemnity, service benefits, UCR, capitation, salary and other approaches to reimbursement of physicians.  The House of Delegates in 1983 reaffirmed support for the following policies:  1)  Freedom for physicians to choose the method of payment for their services and to establish what they believe to be fair and equitable fees;  (2)  Freedom of patients to select their source of care; and;  (3)  Neutral public policy and fair market competition among alternative health care delivery and financing systems.

The Society encourages physicians to provide fee information to patients and to discuss fees in advance of services, where feasible.  It urges physicians to continue and to expand the practice of accepting third party reimbursement as payment in full in cases of financial hardship, and to voluntarily communicate to their patients through appropriate means, their willingness to consider such an arrangement in cases of financial hardship or other extenuating circumstances.  (HOD 1983-3 & 83-46; Reaffirmed HOD 2013; Reaffirmed HOD 2023)