165.000 MANAGED CARE

POSITION STATEMENTS

165.000 MANAGED CARE

165.000 MANAGED CARE

165.834 Payment for Pre-Authorized/Pre-Certified Procedures

The Medical Society of the State of New York continue to advocate for legislation, regulation or other appropriate means to ensure that all health plans including those regulated by ERISA, pay for services that are pre-authorized, or pre-certified by such health plan, including services that are deemed pre-authorized or pre-certified because the physician participates in a “Gold Card” program operated by that health plan.

The New York delegation will advance this resolution for consideration at the next AMA Annual meeting. (HOD 2024 – 59)

165.835 Regulation Against Insurance Company Denials Following Insurer Peer-to-Peer Prior Authorization

The Medical Society of the State of New York reaffirms MSSNY Policies 120.925 and 165.945.
The Medical Society of the State of New York will continue to advocate for the imposition of stronger penalties against insurance companies for inappropriately denying and delaying authorization and payment for patient care.

The Medical Society of the State of New York will advocate for the right of physicians and patients to be able to sue insurance companies for patterns of wrongful denials and delayed payments.

165.836 Making Care Primary–A Capitated Payment Model

The Medical Society of the State of New York will remove from its website webinars or other materials advocating participation in MCP, or at a minimum, add a statement informing NYS physicians and patients of the conflicts of interest and the potential risks of participating in a capitated payment model. (HOD 2024 – 253)

165.837 Timely Claim Filing Limit & Insurance Company Audit Time Limit

MSSNY will work to seek legislative and regulatory changes to establish a timely filing limit of 366 days from date of service. (HOD 2023-258)

165.838 Prior Authorizations by Denials Companies

The Medical Society of the State of New York (MSSNY) will continue to take all necessary steps, including media strategies, to aggressively advocate to state/federal oversight agencies and the State Legislature for relief of abusive health insurer practices that inappropriately delay needed patient care and delay fair payment for delivering this care. (Late Resolution B – HOD 2022; substitute resolution recommended and adopted by Council 1/26/23; reaffirms policies 120.925, 120.944, 165.968, 265.902 and 265.964)

165.839 Non-Compete Agreements and Certain Restrictive Covenants in Professional Contracts

The Medical Society of the State of New York (MSSNY) will create a work group to make recommendations for how best to regulate the use of restrictive covenants in health care delivery in New York State.

MSSNY will comment on the FTC’s proposed rule in a way that is consistent with our current policy and expresses our concerns that non-profit healthcare employers should also be held to the same standard as for-profit employers. (HOD 2022-50; referred to Council, amended and adopted Council 1/26/23; reaffirms policy 155.991)

165.840 Insurers and Vertical Integration

The Medical Society of The State of New York (MSSNY) will seek legislation and regulation to prevent health payers (except non-profit HMO’s) from owning or operating other entities in the health care supply chain.

MSSNY will introduce a resolution to the AMA HOD to seek legislation and regulation to prevent health payers (except non-profit HMO’s) from owning or operating other entities in the health care supply chain. (HOD 2020-64; referred to Council, original language adopted in lieu of recommendation of reaffirmation of 165.876, 4/15/21)

165.840 Insurers and Vertical Integration

165.841 Adverse Impacts of Single Specialty IPA’s

MSSNY will seek legislation and/or regulation to prevent managed care plans from replacing their participating physicians with those of a non-primary care physician single-specialty IPA. MSSNY will seek a study from the AMA relating to the impact of managed care plans replacing their participating physicians with those of a non-primary care physician single specialty IPA. (HOD 2019-120)

165.842 Request for Action on MSSNY Policy 165.933 Managed Care Organization Downcoding

Per MSSNY Policy Statement 165.933, MSSNY will inform the New York State Department of Financial Services (NYSDFS) that managed care organizations continue to routinely downcode or reducing the initially submitted code level to a lesser code level for the Evaluation and Management codes (99XXX), the Eye Exam codes (92XXX) and the Psychiatric Exam codes (90XXX). The MSSNY will seek legislative relief to bar New York State healthcare plans from automatically downcoding any medically necessary service, and from making it necessary de facto for the physician to submit medical record documentation at the time of claim submission. In the absence of legislative relief, the MSSNY will initiate a settlement action against any non-compliant health plan similar to the 2006–2007 action brought against the Blue Cross Blue Shield Association under Love et al V. Blue Cross Blue Shield Association – Case #CV-03-21296, in which the Blue Cross Blue Shield Association was required to rescind its practice of routine downcoding. (HOD 2019-254)

165.843 Ordering Lab and Radiology Tests

The Medical Society of the State of New York will make it known to the New York State Legislature and the NYS Department of Financial Services (DFS) that when out-of-network (OON) physicians order lab tests, diagnostic testing or radiology studies from in-network labs or radiology practices, those orders are often not approved by the plans or honored by the labs or radiology practices. In legislative proposals concerning out-of-network (OON) physicians’ payment problems with managed care plans (ie, proposals that enrollees should be allowed to assign payment to their OON physicians), MSSNY will support the inclusion of language requiring that OON physicians’ orders for lab tests, radiological services and diagnostic tests be approved by plans and honored by in-network labs and radiology practices. (HOD 2018-256)

165.844 Medicare Advantage Plans Seeking Chronic Condition/Diagnosis Data

The Medical Society of the State of New York will urge the Centers for Medicare and Medicaid Services (CMS) to develop formal guidelines for chart requests that Medicare Advantage (MA) plans issue in anticipation of CMS “risk–adjustment/diagnosis data reviews” (reviews in which CMS investigates patients’ health status, with the intent of paying the MA plan more for patients with multiple chronic conditions than for patients with single conditions). These chart request guidelines for Medicare Advantage (MA) plans should set limits on (1) the number of medical records that the MA plan is permitted to list in a single request of this type, and (2) the number of separate requests that the plan is permitted to issue to a physician practice within a given time period. MSSNY will urge the Centers for Medicare and Medicaid Services (CMS) to distribute those guidelines to their contracted Medicare Advantage plans (MA) plans, and require the plans to comply with them. (HOD 2015-255)

165.845 Lombardi Program “Nursing Home without Walls”

The Medical Society of the State of New York will work to ensure the continuity of the Long Term Home Health Care Program (LTHHCP) in managed care contracts and with the AMA will work to ensure that the federal waiver authority which authorized the Long Term Home Health Care Program (LTHHCP) does not expire in September of 2015. MSSNY will urge the New York State Department of Health to conduct a study to evaluate the clinical and cost effectiveness of the Long Term Care Health Care Program (LTHHCP) as opposed to Medicaid Long Term Care to determine the efficacy of one or both models in the evolving health care system. (HOD 2015-108)

165.846 Provider Representative Accessibility

The Medical Society of the State of New York will work with the New York State Department of Financial Services to ensure health insurance companies have sufficient staffing to expeditiously respond to questions from physicians and their staff regarding their patient’s coverage, and that insurers will face financial penalties for failing to ensure such availability.The Medical Society of the State of New York will seek legislation to assure that if an insurer fails to respond to a physician request for pre-authorization of patient care within one day of such request, then that care should be covered. (HOD 2015-68)

165.847 Pharmacy Benefit Managers Interfering with the Progress and Continuity of Treatment

The Medical Society of the State of New York will advocate to ensure that patients stabilized on a particular medication regimen are not forced to change such regimen based upon a change in formulary or insurance coverage change; and that insurers provide continuous coverage for patients for medications previously approved.The Medical Society of the State of New York will seek legislation or other means to ensure health insurance companies provide coverage without need for prior approval for medications needed on an urgent basis, for example, Suboxone for a symptomatic patient in acute opioid withdrawal.The Medical Society of the State of New York will continue to advocate that contractors of health insurance companies, such as Pharmacy Benefit Managers, are subject to the same utilization review rules that health insurers are required to follow. (HOD 2015-57)

165.848 Medicare Advantage Insurer Abuses

The Medical Society of the State of New York will ask the Attorney General to review the practice of managed care plans requesting medical records which are not for quality or utilization review but for business/reimbursement enhancement and that the Attorney General review situations whereby managed care plans, under the guise of doing a health assessment, have personnel visit an insured at home for a medical exam and discussion of the insured’s medical history. MSSNY will urge the Attorney General to ensure that managed care plans which conduct these home “assessment” visits for the purpose of garnering added funds from the plans’ overall administrator (ie, the employer, county state, CMS, etc.) be certain that the plans insureds/patients have a clear understanding of who is coming into their home and the purpose for the examination and history being conducted by the managed care plan’s staff and further that managed care plans obtain clear and explicit consent from patients for these visits. (HOD 2013-252; referred, amended, adopted Council 4/13/2014; Reaffirmed HOD 2024)

165.849: Lack of Transparency in Insurers’ Final Audit Findings

MSSNY should draft legislative proposals regarding third–party insurers’ medical records audits, or work to amend existing proposals, to require that when a final audit finding is accompanied by a refund demand, the insurer must at least state: (a) the identity and medical qualifications of the insurer reviewer; (b) the standards of medical practice and medical record documentation that the reviewer used; (c) the source(s) of any utilization statistics or peer group activities cited; (d) a detailed, patient–by–patient analysis of the alleged insufficiencies in the documentation, including alleged insufficiencies in the documentation of history, exam, and medical decision making; and (e) the full text of the insurer’s most recent in-house policy regarding each service under review. (HOD 2013-258; reaffirms Policies 165.861 and 165.992; Reaffirmed HOD 2023)

165.850: Insurers’ Use of Offsets with Refund Demands

MSSNY will collect examples from physicians of health plans’ attempts to collect alleged overpayments by inappropriately offsetting other payments owed when a physician challenges the alleged overpayments; will present these examples of offsets to the State Department of Financial Services to determine whether these offsets violate Section 3224-b of the Insurance Law; and will continue to seek legislation or regulation that prohibits an insurance company from offsetting payments owed to physicians to pay back alleged overpayments unless the physician executes a clearly stated consent separate from the participation contract. (HOD 2013-58; Reaffirmed HOD 2023)

165.851 Barring Restrictive Covenants: SUNSET HOD 2022

165.852 Payment for Pre-Authorized Services

The Medical Society of the State of New York will seek legislation, regulation, or other appropriate means which requires health insurance companies to certify a patient’s eligibility prior to authorizing the performance of medically necessary services, and once an insurance company has provided such prior authorization and certification, that the authorization is irrevocable for 30 days from the date of the authorization, and the insurer may not seek a refund from the physician after performance of the services due to patient’s lack of coverage at the time of service. (HOD 2012-56; Reaffirmed HOD 2022)

165.853 Protecting New York State Physicians with Multiple Tax ID Numbers

The Medical Society of the State of New York will seek legislation and/or regulation which prevents managed care organizations from requiring physicians to participate under all of their tax ID numbers if they participate under one tax ID number.

The MSSNY Delegation to the American Medical Association (AMA) will bring this resolution forward to the AMA House of Delegates. (HOD 2012-258; Reaffirmed HOD 2022)

165.854 Fair and Free Access to Data from Multiple RHIOs

The Medical Society of the State of New York (MSSNY) will work with the New York eHealth Collaborative (NYeC) and the New York State Department of Health (DOH) to ensure that any physician who subscribes to one RHIO be given the option of participating in any other RHIO’s for no additional fees, whether from the RHIO’s themselves or from EMR portals.

MSSNY will also request that the NYeC and the DOH negotiate for cross-subscription agreements with the RHIOs of neighboring states and advocate for similar agreements within the Nationwide Health Information Network so that patients near the borders of New York also have fair access to the advantages of RHIOs.

MSSNY will make a request to the Health Commissioner to implement regulations that would fund RHIO connections through EMRs without fees to providers for participation. (HOD 2012-103; Reaffirmed HOD 2022

165.855 Identification of Insurance Plans by Payer ID:

MSSNY will:

Urge the NYS Insurance Department to formulate regulations to require greater clarity from NYS health plans with respect to patients’ health insurance cards for identification of the payer’s claim address, product line (Medicare, Medicaid, PPO, HMO, etc.), primary care physician, co-payment(s), deductible, and/or co-insurance amounts, etc.;
Seek to have patients’ health plan cards identify the health plan’s website and direct link to the webpage access for verifying patient eligibility and financial responsibility (i.e. co-payment(s), deductible, co-insurance, etc.);
Seek the development of swipe-card technology in real-time (24/7) with verification.
Urge the NYS Insurance Department to formulate regulations to require greater clarity from NYS health plans with respect to patients’ health insurance cards for identification of the payer’s claim address, product line (Medicare, Medicaid, PPO, HMO, etc.), primary care physician, co-payment(s), deductible, and/or co-insurance amounts, etc.;
Seek to have patients’ health plan cards identify the health plan’s website and direct link to the webpage access for verifying patient eligibility and financial responsibility (i.e. co-payment(s), deductible, co-insurance, etc.);
Seek the development of swipe-card technology in real-time (24/7) with verification. (HOD 2011-250; Reaffirmed HOD 2016-256)

165.856 Restrictive Covenants in Physician Employment Contracts: SUNSET HOD 2022

165.857 Expert Medical Advice by Insurance Companies:

MSSNY to take all appropriate steps necessary to prevent health insurance companies from advertising and providing medical treatment advice to patients when the patient has not received an in-person examination or appropriate medical evaluation. (HOD 2011-62; Reaffirmed HOD 2021)

165.858 Options for Physicians When an Insurance Plan Becomes Insolvent:

MSSNY will (1) seek legislation or regulation that would permit physicians to bill plan subscribers if their insurer became insolvent; and (2) advocate to the State Insurance and Health Departments to assure that health insurance companies remain adequately capitalized to pay patients’ health insurance claims. (HOD 2011-61; Reaffirmed HOD 2021)

165.859 Deductible Transparency:

MSSNY will seek (a) legislation, regulation or other appropriate means to require health insurance companies to provide a patient’s in-network and out-of-network deductible information both on the patient’s insurance card, as well as be available on the health insurance company’s website; and (b) assurance that the deductible information provided on the company’s web site be updated immediately when an insured’s deductible and/or policy has changed. (HOD 2011-60; Reaffirmed HOD 2016-256)

165.860 Provider Agreements:

MSSNY will seek legislation or other appropriate means to prohibit provisions in physician contracts with health insurers that automatically renew the contract at the end of the term. (HOD 2011-57; Reaffirmed HOD 2021)

165.861 Violations of State Insurance Laws by Managed Care Organizations and Private Insurers:

MSSNY will take the following action:

Seek legislation or other appropriate means to a) prohibit health insurance companies from demanding refunds from physicians without providing physicians a detailed audit report which clearly identifies the claims in question and the methodology utilized to arrive at the alleged overpayment amount; b) eliminate or establish a more objective definition of the “abusive billing” exception to the two year current statutory limitation on health plan overpayment recoveries c) permit physicians a meaningful opportunity to appeal a requested refund demand including review by an independent body and d) prohibit automatic offset provisions in physician contracts;
Work to assure that the New York State Insurance Department and Attorney General’s office appropriately investigate and resolve complaints made by physicians regarding violations of the New York State Insurance Law by health plans, including violations of: the Prompt Payment law; laws that limit refund demands and recoveries; and laws which specify a minimum period of time to submit claims;
Educate and encourage physicians to submit suspected violations of these laws to the New York State Insurance Department and Attorney General. (HOD 2011-55; Reaffirmed HOD 2013-258 and 2013-57; Reaffirmed HOD 2021-56)

165.862 Clarification of Chapter 551 Law – Insurance Law Sections 3224-b and 4803(a):

MSSNY will:

Initiate a legal review of the provision of the Chapter 551 Law (Insurance Law Sections 3224-b and 4803(a)) that states that “all accident and health insurers and Article 43 corporations (“insurers”) and health maintenance organizations are required to accept and initiate the processing of physicians’ claims utilizing the American Medical Association’s (AMA’s) current procedural terminology (CPT) codes, reporting guidelines and conventions and the Centers for Medicare & Medicaid Services (CMS) Health Care Common Procedure Coding system (HCPCS)”;
Review (1) whether that section of the law specifically requires insurers to use the AMA CPT coding manual (particularly that manual’s Introductory Section and its narrative policy sections), and (2) whether the law also requires insurers to use all other standard coding conventions as well;
Seek legislation and/or regulatory relief, in regard to the provision in the Chapter 551 Law (Insurance Law Sections 3224-b and 4803(a)) that contains the phrase “codes, reporting guidelines and conventions,” mandating that insurers incorporate all AMA CPT guidelines and conventions, as well as codes, in their payment policies. (HOD 2011-54; Reaffirmed HOD 2021-252 and Sunset Report)

165.863 American Well: SUNSET HOD 2020

165.864 Pre-Authorized Services by Non-Participating Physicians:

MSSNY will seek legislation/regulation mandating that when an out-of-network physician has obtained prior authorization (verbal or written) to perform medically necessary services/procedures, that insurance companies be precluded from utilizing communications (i.e., letters, EOBs, etc.) which contain language urging/directing patients to obtain the requested services from an in-network provider with the threat of being exposed to the imposition of additional out-of-pocket expenses due to their continued use of out-of-network physicians. (HOD 2010-266; Reaffirmed HOD 2020)

165.865 Support Community Rating for Health Insurance:

MSSNY adopted as policy the existing AMA Policy H-165.856, “Health Insurance Market Regulation”:

Health Insurance Market Regulation
Our AMA supports the following principles for health insurance market regulation:

(1) There should be greater national uniformity of market regulation across health insurance markets, regardless of type of sub-market (e.g., large group, small group, individual), geographic location, or type of health plan;

(2) State variation in market regulation is permissible so long as states demonstrate that departures from national regulations would not drive up the number of uninsured, and so long as variations do not unduly hamper the development of multi-state group purchasing alliances, or create adverse selection;

(3) Risk-related subsidies such as subsidies for high-risk pools, reinsurance, and risk adjustment should be financed through general tax revenues rather than through strict community rating or premium surcharges;

(4) Strict community rating should be replaced with modified community rating, risk bands, or risk corridors. Although some degree of age rating is acceptable, an individual’s genetic information should not be used to determine his or her premium;

(5) Insured individuals should be protected by guaranteed renewability;

(6) Guaranteed renewability regulations and multi-year contracts may include provisions allowing insurers to single out individuals for rate changes or other incentives related to changes in controllable lifestyle choices;

(7) Guaranteed issue regulations should be rescinded;

(8) Health insurance coverage of pre-existing conditions with guaranteed issue within the context of an individual mandate, in addition to guaranteed renewability.

(9) Insured individuals wishing to switch plans should be subject to a lesser degree of risk rating and pre-existing conditions limitations than individuals who are newly seeking coverage; and

(10) The regulatory environment should enable rather than impede private market innovation in product development and purchasing arrangements. Specifically:

(a) Legislative and regulatory barriers to the formation and operation of group purchasing alliances should, in general, be removed; (b) Benefit mandates should be minimized to allow markets to determine benefit packages and permit a wide choice of coverage options; and (c) Any legislative and regulatory barriers to the development of multi-year insurance contracts should be identified and removed. (CMS Rep. 7, A-03; Reaffirmed: CMS Rep. 6, A-05; Reaffirmation A-07; Reaffirmed: CMS Rep. 2, I-07; Reaffirmed: BOT Rep. 7, A-09; Res. 129, A-09) (MSSNY HOD 2010-263; Reaffirmed HOD 2020)

165.866 Online Access to Managed Care Organizations’ Professional Relations Department:

MSSNY will:

draft a legislative proposal requiring New York State private insurers and managed care organizations to provide physicians with access to their Professional or Provider Relations staff, so that the physicians can request assistance from these representatives;

recommend that, in order to accommodate participating physicians’ questions and requests for assistance, the private insurers and managed care organizations augment their present Internet and e-mail capabilities by (1) placing their Professional/Provider Relations representatives’ contact information on-line, and/or (2) providing lists of representatives’ territories by zip code, including the phone, fax, and e-mail address of the Professional / Provider Relations representative responsible for each zip code;

recommend punitive measures, applicable to the insurers themselves, that would apply if an insurer’s Professional/Provider Relations staff fails to respond in a timely manner to a participating physician’s question or request for assistance; such punitive measures might include fines, performance reviews and/or a requirement that the insurer pay the claim. (HOD 2010-255; Reaffirmed HOD 2015-68)

165.867 Timely Discussion Between Treating Physician and the Insurance Company’s Medical Director When Services are Denied Based on Medical Necessity:

MSSNY will seek legislation and/or regulation to assure that the Insurance Company’s Medical Director be directly available, within 2 business days, to discuss a denial based on medical necessity with the treating physician. (HOD 2010-252; Reaffirmed HOD 2020)

165.868 United Healthcare/Oxford Subscriber Identification Cards: SUNSET HOD 2020

165.869 Participating Provider Lists:

MSSNY will request that the State Superintendent of Financial Services enforce the law that requires health insurers to update their online participating provider lists within 15 days of a change in participation status. (HOD 2010-59; Amended and reaffirmed HOD 2020)

165.870 Minimum Medical Loss Ratio:

MSSNY will support legislation that would
(1) require health insurers to spend a minimum of 85% of their collected premiums on medical care as a means of ensuring that insurance companies become more efficient while making health care more affordable and

(2) if a health insurance company fails to maintain an 85% medical loss ratio, any excess be refunded to the premium payers. (HOD 2010-55; Reaffirmed HOD 2020)

165.871 Healthcare Reform:

MSSNY will continue to advocate for the end of abusive managed care practices that threaten the viability of physician practices and patient access to care. (HOD 2010-54; Reaffirmed HOD 2020)

165.872 Insurance Industry Antitrust Protection:

MSSNY will support repeal of antitrust exemptions afforded to health insurance companies under federal law that may permit health insurance companies excessive domination and anti-competitive control over physicians in any given market. (HOD 2010-53; Reaffirmed HOD 2020; Reaffirmed Council 11/21/24)

165.873 Discriminatory Treatment of Psychiatrists’ Use of E/M Codes:

MSSNY will call upon the New York State Department of Financial Services and the New York State Department of Health to enforce New York Insurance Law §3224-b (Chapter 551 of the Laws of 2006) and to inform all health plans in writing that the provisions of New York Insurance Law §3224-b mandate that:

if a health plan covers (i.e., accepts, processes and provides reimbursement for) Evaluation and Management (E/M) services provided by physicians in their office or in the hospital, then health plans must accept, process and reimburse claims submitted by psychiatrists for E/M services in the same manner and to the same extent as provided for E/M services provided by physicians in other specialties (subject to any limitations on coverage of the treatment of mental illness under the health plan and permitted by law);

to the extent that a health plan provides coverage for specific E/M codes, health plans must accept and process claims for those E/M codes submitted by physicians without limitation or restriction based upon the physician’s medical specialty;

health plans cannot restrict psychiatrists to submitting claims only for psychiatry procedure codes and must permit psychiatrists as well as all other physicians to use all E/M codes covered under the health plan. (HOD 2009-263; Reaffirmed HOD 2019)

165.874 Collaborative Efforts with the Bar Association:

MSSNY will:

support collaborative efforts with the bar association to remove the Employee Retirement Income Security Act of 1974 (‘ERISA’) shield that pre-empts action against health plans for the adverse outcomes that result from their delays or their medical decision making;

ask the American Medical Association (AMA) to support collaborative efforts with the bar association to remove the ‘ERISA’ shield that pre-empts action against health plans for the adverse outcomes that result from their delays or their medical decision making; and,

together with the AMA, utilize this collaboration and the American Bar Association (ABA) policy that supports alternative dispute resolution (ADR) mechanisms to facilitate movement toward medical liability reform. (HOD 2009-69; Reaffirmed HOD 2019)

165.875 Condemnation and Reporting of Unilateral Physician Fee Reduction by Any Health Plan:

MSSNY will

(1) condemn the unilateral reduction of fees paid to participating physicians by any health plan;

(2) present this issue promptly to the Governor of the State of New York, the Majority and Minority Leaders of the State Senate, the Speaker and Minority Leader of the State Assembly and the Superintendent of Insurance; and

(3) have the New York Delegation to the American Medical Association bring this issue to the AMA’s next Annual Meeting for action on the federal level. (HOD 2009-67; Reaffirmed HOD 2019)

165.876 Ownership of Managed Care Organizations:

MSSNY will advocate for legislation or regulation that would prohibit a health insurance company from having a financial interest in any subsidiary or other organization which may negatively influence health care spending, such as restrictions on patient access to care or reductions in physician reimbursement. (HOD 2009-61; Reaffirmed HOD 2019)

165.877 Increase Medical Loss Ratios:

MSSNY will seek legislation or regulation requiring

(1) health insurers to increase their medical loss ratios as well as mandating that they meet a minimum medical loss ratio; and

(2) increased transparency of health insurers’ premium dollars, that they publicly disclose information on their medical loss ratios in an easily understandable manner, including allocations for salaries and administrative costs.

Also, MSSNY should collect, collate, compare and publish up-to-date data on health insurers doing business in New York State. (HOD 2009-60; Reaffirmed HOD 2019)

165.878 Insurance Company Merger: SUNSET HOD 2019

165.879 Medical Smart Cards: SUNSET HOD 2019

165.890 Guidelines for Executive Compensation in Health Insurance Companies:

MSSNY will urge the enactment of federal legislation or regulation that will establish guidelines for executive compensation in health insurance companies that assures appropriate and responsible allocation of resources for health care delivery. (HOD 2008-67; Reaffirmed HOD 2018)

165.891 Patient-Directed Educational Campaign Regarding Managed Care Organizations:

As part of its ongoing efforts to achieve meaningful reform of abusive managed care practices, MSSNY will (a) utilize educational materials that encourage physician and patient grassroots advocacy; and (b) work to educate physicians, the public and patients regarding the increasing threat to the health care delivery system caused by excessive health plan market share, profits and executive compensation. (HOD 2008-64; Reaffirmed HOD 2018)

165.892 Contract and Fee Schedule Disclosure:

MSSNY to seek legislation, regulation or other appropriate means to compel health plans to provide physicians with full written contracts with all changes highlighted, a full fee schedule applicable to the physician’s specialty, and a written summary of such changes, each time they renew the contract. (HOD 2008-59; Reaffirmed HOD 2018)

165.892 Contract and Fee Schedule Disclosure:

165.893 Changes in the Overpayment Recovery Law:

MSSNY will seek legislation, regulation or other appropriate means to:

assure that meaningful fines and penalties are imposed on health plans that violate the current two-year statutory limitation on health plan refund demands as well as the requirement that health plans provide 30 days notice before initiating efforts to recover an alleged overpayment;
limit the time that health plans can seek repayment of overpayments to physicians to the same time that a physician has to submit a claim;
require that, in the event a physician has paid a recovery to a Managed Care Organization due to erroneously billing the MCO rather than the correct insurer (e.g. no-fault or Workers’ Compensation), the appropriate responsible party be required to honor a claim for the services rendered for a period of 60 days from the date of the recovery. (HOD 08-58; Reaffirmed HOD 2011-55; Reaffirmed HOD 2021)

MSSNY recommends that section 3224-B of the insurance law be amended to require health plans to initiate overpayment proceedings within 2 months (60 days) from the date the claim was paid and will continue to seek the enactment of legislation; regulatory or other means to prohibit using extrapolation to determine refund demand amounts in the absence of fraud or intentional misconduct. (HOD 2013-55 and 56; Reaffirmed HOD 2021)

MSSNY will work to remove all references to fraud and/or abuse from the State’s refund demand “look back” law and also amend Assembly Bill A.1538 (on the state’s refund demand “look back” law) to (a) require that the law define “reasonable belief” and (b) require insurers to support their “fraud and abuse” allegations with detailed analyses of alleged deficiencies in the charts. MSSNY will also continue to seek legislation that would eliminate the “abusive billing” exception to the statutory look back limit. (HOD 2013-57; Reaffirmed HOD 2021)

165.894 Tracking Electronic Claims:

MSSNY will seek legislation or regulation mandating health payment plans that require electronic claims submission be required to make available the means of tracking the claim electronically as it is processed. (HOD 2007-265; Reaffirmed HOD 2017)

165.895 Requirement for MCOs to Provide Education and Training Initiatives:

MSSNY will legislation that would require: (1) each third-party insurer to develop and implement a formal Local Provider Education and Training (LPET) Initiative, designed to give panel physicians all the information they need now and in the future about the carrier’s policies, procedures, and coverage issues, in order to receive appropriate reimbursement; and (2) third-party insurers to provide dedicated and identifiable staff, telephone lines, and e-mail addresses, whereby physicians can contact the carrier in order to fully understand and abide by the carrier’s policies and procedures. (HOD 2007-256; Reaffirmed HOD 2017)

165.896 Retraction Letters and Erroneous Termination Letters:

MSSNY will work with the appropriate New York State regulatory agency to draft regulations requiring managed care organizations (MCOs) to issue letters of retraction when the MCO has erroneously informed patients that a physician is no longer participating, when the physician has merely filed a request to change the demographic information in the plan’s Provider File. (HOD 2007-254; Reaffirmed HOD 2017)

165.897 MCOs Use of Pre-Payment Claim Reviews to Circumvent the New York State Prompt Payment Law:

MSSNY will:

(1) using the Hassle Factor Form, solicit and compile examples of prepayment claim reviews initiated by managed care organizations where the physician has received no prior notification of aberrant coding or claim submission practices;

(2) review these examples to determine whether the managed care organizations are in violation of the New York State Prompt Payment Law or related regulatory directives, such as the New York State Insurance Department Regulation # 178 (11 NYCRR 217) (Prompt Payment of Health Insurance Claims) or Article 26 of the Unfair Claim Settlement Practices law (Section 2601); and

(3) urge the New York State Insurance Department to take appropriate action against these managed care organizations if it is determined that the MCOs are indeed in violation of the relevant statutes or regulations through their use of erroneous pre-payment reviews. (HOD 2007-253; Reaffirmed HOD 2017)

165.898 Health Care Reinvestment Fund:

MSSNY will support legislation to (1) create a health care reinvestment fund to assure that a portion of health insurer profits are returned to physicians and hospitals within the service area served by each insurer; and (2) limit an insurer’s medical loss ratio. (HOD 2007-110; Reaffirmed HOD 2017)

165.899 Phlebotomy Services by Physician Offices:

MSSNY to oppose penalties on physicians for referring patients for out-of-network services and work with health insurance plans to appropriately reimburse the expense for phlebotomy services at physician offices. (HOD 2007-73; Reaffirmed HOD 2017)

165.900 Bar For-Profit Health Plan Operations:

In addition to MSSNY’s seeking legislation to bar for-profit plan health insurance operations in New York State, it should also (1) publicize the better claims settlement and quality of care indicators of non-profit plans over for-profit plans; (2) take all steps necessary to assure that health insurers seeking to convert to for-profit status are required to rectify frequent complaints and address other patient and physician concerns as a condition of being permitted to convert to for-profit status; and (3) continue to seek legislation and regulation to rectify the abusive claims processing practices of all health plans. (HOD 2007-72; Reaffirmed HOD 2008-66; Reaffirmed HOD 2009-56; Reaffirmed HOD 2010-56; Reaffirmed HOD 2020)

165.901 Health Care Providers and Antitrust:

In acknowledging that federal antitrust agencies have consistently placed physicians under a far higher level of scrutiny than is warranted by their comparative economic strength in today’s health care system, MSSNY to pursue relaxation or exemption of antitrust laws as applies to physicians in order to promote greater connectivity, and thus improve health care outcomes and cost savings that will result from improved outcomes. (HOD 2007-71; reaffirmed Council 11/20/08; Reaffirmed HOD 2009-56; Reaffirmed HOD 2010-53 & 54; Reaffirmed HOD 2020)

165.902 Insurance Product Oversight by the Superintendent of Insurance:

MSSNY supports the law requiring insurance companies doing business in New York State to submit to the Superintendent of Financial Services all proposed changes in products and premium rates for prior review and approval. (HOD 2007-70; Reaffirmed HOD 2010-54; Amended and reaffirmed HOD 2020)

165.903 Contract Termination – Merged MCOs:

MSSNY continues to support the ability of a physician to choose the health plans and the health plan products with which they will participate, and continues to oppose efforts by health plans to require physicians to participate with all affiliates of a particular plan or all products offered by a particular plan; and

Should health plans continue to have the ability to require physicians to participate in all its affiliates, MSSNY will advocate for legislation to assure that:

a) newly merged health plans are required to follow the termination protocols of the health plan that provides more beneficial terms to the physician; and
b) permits the physician wishing to terminate from the health plan and all its affiliates to execute such termination by contacting the plan with which the physician originally contracted. (HOD 2007-69; Reaffirmed HOD 2016-52)

165.904 Reform of Managed Care Denial Process:

MSSNY will:

(1) support legislation or regulation requiring health plans to submit quarterly detailed schedules of reimbursement denials, including the number of denials, the amount, and the reasons for denials to deter abusive practices and improve quality of care;

(2) continue sharing with all relevant state agencies the most frequent causes of health plan denials reported to MSSNY, so that the Superintendent of Insurance and Commissioner of Health may investigate such denials; and

(3) urge the Superintendent of Insurance to investigate patterns of inappropriate denials by health plans as part of their routine market conduct audits. (HOD 2007-68; Reaffirmed HOD 2017)

165.905 Reimbursement for Pre-Authorized Services Subsequently Denied by MCOs:

MSSNY will take all appropriate steps to assure that physicians have the ability to seek payment from patients where a health plan subsequently denies a pre-authorized service and seek to assure that the insurer notify the patient regarding their financial responsibility. (HOD 2007-67; Reaffirmed HOD 2017)

165.906 Hard-Coded Personal Computer Dates as Proof of Timely Filing of Paper Claims:

Legislation, regulation, or other appropriate means will be sought by MSSNY to require all insurers, including workers compensation carriers, to accept hard-coded-system generated data as proof that a paper claim was timely filed, provided the physician attests that the claim was mailed on or about the day the claim was generated. (HOD 2007-65; Reaffirmed HOD 2017)

165.907 Clarification of the New York State Current Procedural Terminology Uniformity Law:

MSSNY should take all the steps, including legislation, necessary to assure that health plans comply with and abide by the American Medical Association coding policy statements that are contained in the yearly AMA CPT coding manual. (HOD 2007-61; Reaffirmed HOD 2017; Reaffirmed HOD 2021-252)

165.908 Insurer Practices Oversight by the Appropriate State Agencies:

MSSNY will seek legislation, regulation or other appropriate means to prohibit health insurance companies from unilaterally changing any material contract provision; and, if unable to obtain such change to the law, seek to assure that such material contract changes are reviewed and subject to prior approval by appropriate state agencies, including the Departments of Health and Insurance, with interested groups being given the opportunity to provide comment. (HOD 2007-58; Reaffirmed HOD 2011-57; Reaffirmed HOD 2018 in lieu of resolution 58)

165.909 Psychiatric Medication Formulary Exclusion:

MSSNY should: (1) promote passage of legislation that would allow patients who, based upon the judgment of the treating physician, demonstrate stability on current medication regimens not be required to be subjected to therapeutic equivalent changes based on formulary preferences; and (2) work with the Insurance Department and the Health Department to enable a patient or physician to request an exemption from a health plan when the required drug is placed on a high-cost tier. (HOD 2007-56; Reaffirmed HOD 2017)

165.910 Codification and Access of All Formularies:

MSSNY will: (1) advocate for the creation of a unified industry-supported website that lists the formularies of all health plans and Part D plans; (2) explore the feasibility of requiring a plan to format their formularies in a nationally recognized standard that would facilitate physician Electronic Medical Record interfaces; and (3) seek to assure that health plan prior authorization rules for prescribing medications be clear and concise. (HOD 2007-55; Reaffirmed HOD 2017)

165.911 Physician’s Ability to Refer to Imaging Center of Choice:

MSSNY will – (1) ask the New York State Department of Health and the New York State Insurance Department to investigate whether there are adverse health care consequences for patients as a result of managed care organizations: a) removing the ability of a physician to refer a patient to the imaging center of their choice and b) scheduling imaging services without the input of the referring physician; and (2) endeavor to limit the ability of third parties to intrude into the clinical-decision making authority of physicians. (Council 11/2/06; Reaffirmed HOD 2016)

165.912 Electronic Data Interchange (EDI) for Claims Appeals:

MSSNY will draft model legislation requiring each managed care organization to establish an electronic data interchange (EDI) function through which physician participants can appeal denied claims, online or via a secure web-based Internet site, and since this EDI claims appeal project would significantly reduce costs for employee health insurance, MSSNY enlist the support of the appropriate New York State Employer Association. (HOD 2006-254; Reaffirmed HOD 2016)

165.913 Protection Against Being Assigned:

MSSNY will seek legislation, regulation or other appropriate means to assure that any managed care company or other entity which assigns its provider network, to promptly notify all entities to which the services of that provider has been assigned, and that such legislation or regulation specify that a managed care company or other entity be responsible for any financial loss suffered by a physician because of a lack of prompt notification by such managed care company or entity that the physician resigned from such network. (HOD 2006-64; Reaffirmed HOD 2016)

165.914 Standardized Managed Care Participating Agreements:

MSSNY will seek regulation requiring managed care organizations licensed to do business in New York, to utilize standard physician participation agreements containing easily identifiable contract provisions, with clearly delineated standard disclosures, thereby enabling physicians to have a clear understanding of their rights and responsibilities as well as the rights and responsibilities of the contracting entity; and that if an insuring entity elects to incorporate a provision in a participating physician agreement which may depart from the norm of a standard contract provision, i.e., allowing that entity to assign/sell their listing of participating physicians to other entities (a concept referred to as a “silent PPO”), that these provisions be included in a separate and easily identifiable section of the contract. (HOD 2005-252; Reaffirmed HOD 2015)

165.915 “Indentured Servitude” with Managed Care Organizations (MCOs) and Third-Part Administrators (TPAs):

MSSNY will seek legislation to require MCOs and TPAs to notify physicians when their contract with the MCO or TPA has been assigned and the amount of the discount fee schedule associated with the assignment of said contract. (HOD 2005-63; Reaffirmed HOD 2006-64; Reaffirmed HOD 2016)

165.916 Patient Responsibility for Services Denied by Managed Care Organizations due to Coverage Parameters:

MSSNY encourages all managed care organizations licensed in this state, to adopt a policy allowing participating physicians to bill patients for those services that have been denied due to the company’s internal coverage parameters, provided that the patient knew in advance that the procedure would not be covered and still chose to have the procedure performed. (Council 6/3/04; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.917 Carriers’ Failure to Obey PHL 4406-c (5A) Release of Fee Schedule:

MSSNY will work with the NYS DOH to amend appropriate provisions of law to assign monetary penalties for failure to comply with requests for fee schedules. Failing legislative relief, MSSNY will study the feasibility of bringing appropriate legal action against carriers in New York who are identified as refusing to provide requested fee schedule data. (HOD 2003-52; Reaffirmed HOD 2013; Reaffirmed HOD 2016-56; Reaffirmed HOD 2022-61)

165.918 Time Limit for Retrospective Denials:

MSSNY continues in its efforts to seek legislation, regulation or other appropriate means to prohibit retrospective refund requests by health plans in all circumstances except fraud. Short of achieving a complete ban on retrospective refund requests, MSSNY seek legislation, regulation or other appropriate means to limit to 90 days the time within which a health plan can seek such a refund, or other significant restrictions on the ability of health plans to seek such refunds, such as limiting the time that a health plan can seek a refund to the same time that a physician has to file a claim with such health plan. (HOD 2003-69; Reaffirmed HOD 2013; Reaffirmed HOD in lieu of 2017-108; Reaffirmed HOD in lieu of 2022-61 and 2022-250)

165.919 The Elimination of “Silent PPOs”:

MSSNY will seek legislation:

to prohibit a health plan from selling, renting or assigning a physician’s agreement to provide a discount without the physician’s expressed approval;
ensuring that a panel or network physician’s services be subjected to a fee discount only when the patient presents an insurance identification card identifying the plan that has contracted with the physician; and
to make “silent PPOs” unlawful in New York State. (HOD 2002-270; Reaffirmed HOD 2013; Reaffirmed HOD 2023)

165.920 Adoption of the Use of Unlisted Procedure Code Series in the Referral Process for Managed Care and Private Insurers: SUNSET HOD 2013

165.921 Fee Schedules: SUNSET HOD 2013

165.922 Resolution to Allow Complete Treatment: SUNSET HOD 2013

165.923 Approval by Insurance Companies to Providers:

MSSNY will seek legislation assuring that insurance companies remain obligated to pay for all services that have been pre-authorized, unless such authorization was obtained fraudulently. (HOD 2002-73; Reaffirmed HOD 2004-83; HOD 2007-67; HOD 2008-50; Reaffirmed HOD 2018 in lieu of resolution 59)

165.924 Health Plan Fee Schedule Releases:

MSSNY will continue to monitor the activities of health plans as they pertain to the violation of Section 4406-c (5-a) of the New York State Public Health Law, specifically, the refusal of health plans to release their fee schedules to physicians; and will continue to encourage members to report to the MSSNY health plans that violate Section 4406-c (5-a) of the New York State Public Health Law. (HOD 2001-259; Updated 2011 HOD; Amended and Reaffirmed HOD 2021)

165.926 Deductible Should Be Prorated to Make Them Equitable for Enrollees:

It is MSSNY’s policy that the New York State Department of Insurance require insurers to prorate annual deductibles to the date of contract enrollment.

MSSNY introduced a resolution asking the American Medical Association’s House of Delegates to seek legislation, regulation or other appropriate relief to require insurers to prorate annual deductibles to the date of contract enrollment. (HOD 2001-67; Reaffirmed HOD 2011; Reaffirmed HOD 2021)

165.927 Physicians Should Not Be Financially Liable in Retrospective Denials:

MSSNY will seek, by legislation, regulation, or other appropriate means, the following:
(a) To prohibit retrospective denials caused by the employer’s failure to pay premiums in a timely fashion, or the employer failing to provide the carrier with timely and correct eligibility data.

(b) To prohibit a payor from attempting to retroactively deny or adjust a claim after payment is made to a physician for care rendered.

(c) That should obtaining a complete ban on retrospective denials or adjustments not be able to be enacted, seek to prohibit insurers from making a retroactive denial and/or adjustment of a reimbursement beyond 90 days after payment is made to the physician for care rendered.

(d) In the event that an insurer attempts to issue a retroactive denial or adjustment after payment is made to the physician, to require such insurer to provide the physician with a detailed explanation on each patient as to the circumstances surrounding the retroactive adjustment or reimbursement and/or denial, and provide the physician with an effective opportunity to counter the reasons for the adjustment.

(e) In the event that an insurer has already paid the physician for a service, but later issues a retrospective denial or adjustment, to prohibit such insurer from attempting to recoup its payments for that service via offsets on payments for other services.

MSSNY will work regularly with all appropriate regulatory agencies to insure that the regulators are kept apprised of payment policies employed by plans which do not comport with the law. (HOD 2001-65; Reaffirmed HOD 2010-259; Reaffirmed HOD 2019-63; Reaffirmed HOD 2022 in lieu of 2022-251)

165.928 Rejection of Milliman & Robertson as Standard of Care: SUNSET HOD 2024

165.929 Health Plan’s Improper and Bullying Techniques to Force Physicians to Inappropriately Downcode E&M Services: SUNSET HOD 2014

165.930 Health Insurance Eligibility Electronic Verification System: SUNSET HOD 2024

165.931 Managed Care Organizations Should Supply Complete Fee Schedules and Include Cost of Living Adjustment (COLA) Guarantees in Contracts: SUNSET HOD 2014

165.932 Health Care Plans:

MSSNY will seek regulation and/or legislation that once a health care plan has sold its product to a consumer, the health care plan is not permitted to limit the territory it covers during the policy term. (HOD 2000-254; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.933 Downcoding:

MSSNY will seek legislative relief to (a) preclude down-coding and/or bundling of any medically necessary service by health care plans doing business in New York State and Computer Sciences Corporation/Medicaid; (b) prevent health care plans and Computer Sciences Corporation/Medicaid from the down-coding of medical services without first obtaining, at the expense of the health care plan, copies of patients’ medical record and justifying the change in reimbursement; (c) prevent health care plans and Computer Sciences Corporation/Medicaid from requiring automatic and mandatory submission of medical record documentation for Evaluation and Management (E&M) codes at the time of claim submission. (HOD 2000-253; Reaffirmed HOD 2013; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.934 AMA Policy on ERISA: SUNSET HOD 2021

165.935 HMO Carve-outs: SUNSET HOD 2014

165.936 Mandated Use of Hospitals by Managed Care Companies: SUNSET HOD 2014

165.937 Full Adoption of the National Specialty Societies’ Practice Parameter Guidelines by Third-Party Insurers:

MSSNY will seek legislative or regulatory relief to require third-party insurers in New York State to utilize practice guidelines for utilization review purposes as developed by the appropriate national or state specialty societies. (HOD 2000-72; Reaffirmed HOD 2003-268 & 278; Reaffirmed HOD 2013; Reaffirmed HOD 2023)

165.938 Patient’s Choice:

MSSNY will seek New York and Federal legislation which requires a health care plan to permit patients to access, without restriction, any and all providers participating with the plan who provide medical or diagnostic services. (HOD 2000-63; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.939 Insurance Company Participating Provider Networks:

MSSNY will pursue a legislative remedy to ensure that when any health care plan entity publishes a list of participating providers as part of an advertising campaign to enroll new members for a future time period (or upcoming coverage period), that said list accurately reflect the physicians who will be participating during the time period the insurance will be in effect and not merely the physicians who are currently participating as of the time of the advertising campaign. (HOD 2000-62; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.940 Full Disclosure of All Documents Related to Third-Party Insurer Contracts:

MSSNY will seek legislation, regulation and/or enforcement of current laws and regulations to allow for informed decision-making by physicians. MSSNY urges third-party payors to provide all pertinent information prior to the signing of any participation agreement including the provision of the fee schedule. (HOD 2000-61; Reaffirmed HOD 2001-258; Reaffirmed HOD 2003-268 & 278; Modified and reaffirmed HOD 2013; Reaffirmed HOD 2023)

165.941 Coordination of Pharmacy Benefit into Existing Health Plans:

MSSNY will seek legislation which would preclude health care plans from requiring physicians to deviate from an already established drug regimen (formulary) based solely upon cost factors associated with less expensive, but possibly less effective drugs. The aforementioned legislation should include coordination of a pharmacy benefit into already existing health plans. MSSNY will strongly encourage the development and utilization of technologies to allow physicians to instantly access the established drug of any health plan with which the physician maintains a contractual relationship. (HOD 2000-56; Reaffirmed HOD 2001-53; Reaffirmed HOD 2011; Reaffirmed HOD 2015-57)

165.942 Education About HMOs as Payors for Health Care: SUNSET HOD 2014

165.943 Require Health Insurance Carriers to Report Medical Loss Data that Reflects All Levels of Managed Care Subcontracting: SUNSET HOD 2014

165.944 HMO Requirements that Physician Providers Use Only Approved Laboratories: SUNSET HOD 2014

165.945 Qualification of Precertification Reviewers:

MSSNY will support legislation requiring MCOs to utilize New York State practicing physicians as pre-certification reviewers. MSSNY shall support legislation requiring that any pre-certification denial be reviewed by a physician in active practice in New York State in the same specialty or subspecialty as the physician performing the procedure, and that such legislation include provisions which would require managed care organizations to utilize medical protocol and review criteria approved by New York State practicing physicians who participate in the plan. (HOD 1999-91; Reaffirmed HOD 2011-107; Reaffirmed HOD 2021; Reaffirmed HOD 2024-60)

165.946 Information Included on Health Insurance Identification Cards:

MSSNY reaffirms its commitment to the positions embodied in Resolution 97-56, (Policy 165.981) and, in addition, MSSNY will work with payors to encourage the use of “smart cards” which would encode information, including but not limited to, the patient’s eligibility data, co-pay, type of policy, effective policy dates, company address and appropriate phone number, I.D. number, group number, and the name of any entities with whom the MCO has subcontracted to pay for specific “carved-out” services. MSSNY will work with payors to encourage the use of a standard encryption format so that one machine is capable of reading data from all companies, and that the smart card reader be made available to all physicians at a reasonable price. MSSNY will seek through legislation or regulation a requirement that payors provide immediately, upon application for enrollment, a temporary health insurance identification card providing information including but not limited to notice of effective date of eligibility. (HOD 1999-87; Reaffirmed HOD 2000-272; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.947 HMO Physician Indemnification:

MSSNY will seek legislation requiring health care plans to indemnify and hold harmless a participating physician who acts in good faith and is sued by an insured patient for outcomes that result when the physician’s recommended course of action has been denied by the health care plan. (HOD 1999-81; Reaffirmed HOD 2014; Reaffirmed HOD 2020-56)

165.948 Community Rating for Medical Coverage:

MSSNY will work with the American Medical Association to secure passage of federal legislation to: (a) replace the current tax exclusion of employer-provided coverage with a refundable tax credit for each individual who receives coverage as a benefit of employment, or who purchases health insurance in the private market; (b) expand the definition of health benefits under Section 106 of the Internal Revenue Code to include employers’ contributions to their employees’ purchase of individual health insurance; (c) eliminate the restrictions on the availability of MSAs; and, (d) enable the creation of risk pooling cooperatives to foster an environment in which individually owned insurance could be purchased economically. MSSNY will support all legislative/ regulatory efforts to examine the need to implement effective state insurance reform that would facilitate the purchase of individual and group coverage for all New Yorkers at an affordable cost. (HOD 1999-68; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.949 Quarterly Publication of Supplementary Provider Lists for HMO Subscribers:
SUNSET HOD 2014

165.950 Require that HMO Subscribers Select a Primary Care Physician Within 30 Days or be Assigned One by the Plan, as per the Requirements of the NYS Medicaid Managed Care Guidelines Issued by the NYS Department of Health: SUNSET HOD 2024

165.951 Quarterly Financial Disclosures:

MSSNY will seek the introduction of legislation and/or regulation to require HMOs and insurance companies to provide quarterly: a standard financial report, a statement of financial reserves, and a statement of outstanding debt including “disputed” and “undisputed” claims to the Medical Society of the State of New York and that MSSNY shall seek the introduction of legislation and/or regulation to require HMOs and insurance companies to report to the State all transfers of funds in excess of $250,000 not in the ordinary course of business within 15 days of such transfer and that such legislation and/or regulation should require HMOs and insurance companies to provide, upon request by MSSNY, an independent audit of a quarterly report when in the quarter for which the report was issued, such plan has transferred funds in excess of $250,000 not in the ordinary course of business. (HOD 1999-59; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.952 Managed Care Organizations’ Restricting Practice of Credentialed Physicians:

MSSNY will seek legislation or regulation barring managed care organizations from limiting, by internal policy or refusal of payment, qualified physicians from practicing within the scope of their abilities, license and training. (HOD 1999-54; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.953 Accountability for HMO Termination of a Physician by Mistake:

MSSNY will actively seek legislation or regulation which holds an HMO or managed care plan accountable for all damages incurred by a physician as the result of termination notification which was made in error, to the physician’s patients. MSSNY will take all action necessary to assure that physicians are informed of their rights when terminated by a plan or when patients are inappropriately notified of a physician’s termination from the plan. (HOD 1999-53; Reaffirmed HOD 2007-254; Reaffirmed HOD 2017

165.954 Prudent Layperson – 911 Calls:

MSSNY reaffirms its support of the prudent layperson standard for emergency medical service and opposes triage by 911 dispatch which divert 911 (Emergency Dispatch) calls to non-emergency facilities, other than birthing centers or those facilities identified by the local REMAC (Regional Medical Advisory Committee) because of geographic constraints. (Council 10/28/98; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.955 The Need for Patients to be Informed as to the Difference Between Physicians and Other Types of Health Care Provides so as to Allow the Patient to Make a Choice of a Physician or Other Health Care Provider Based in Informed Consent:

MSSNY shall seek enactment of State and Federal legislation mandating that patients be notified whenever a health care provider other than a physician will provide care to a patient. (HOD 1998-57, Reaffirmed HOD 1999-83; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.956 Disclosure of Conversion Options by Medicare Managed Care Organizations to Prospective Enrollees Previously Covered by Employer-Sponsored Insurance Contracts: SUNSET HOD 2014

165.957 Re-credentialing of Physicians in Merged Managed Care Organizations:

The Medical Society of the State of New York will seek to assure, through whatever means appropriate, that when a contract between a managed care organization and credentialed physicians is transferred, merged or consolidated into another organization, the cost associated with re-credentialing of already credentialed participating physicians be borne by the new entity. (HOD 1998-207; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.958 Crediting Capitated Payment: SUNSET HOD 2024

165.959 Channeling of Eye Examinations to Optometrists:

It is the position of MSSNY that third-party payors not be permitted to shift patients from ophthalmologists to optometrists, that third-party payors not designate optometrists as primary eye care providers; and that MSSNY will issue a letter to all third-party payors operating in New York State, putting forth organized medicine’s strong opposition to channeling enrollees to optometrists and other non-physicians and opposing the exclusion of ophthalmologist from refractive eye examinations, routine eye examinations, or primary eye care.

MSSNY will coordinate efforts with medical specialty societies to introduce legislation prohibiting third-party payors from mandating or encouraging that routine and refractive examinations be performed by optometrists rather than by ophthalmologists. (HOD 98-79; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.960 Capitation:

The Medical Society of the State of New York will seek legislation or regulation which (a) defines acceptable financial risk arrangements between physicians and managed care plans to minimize the potential for the reduction or limitation of appropriate access to medically necessary services; and (b) ensures that managed care plan enrollees be entitled to know the type of financial risk arrangement health plans have in place for their providers. (HOD 1998-72; Reaffirmed HOD 1999-268; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.961 Enforcement of Disclosure Laws Under Managed Care Bill of Rights:

That the Medical Society of the State of New York petition the state legislature, Attorney General, and the Governor to (a) strictly enforce the current law and (b) increase the

fine to a sufficient level to encourage compliance and (c) clearly stipulate that such fines shall not be paid from money budgeted for the provision of health care. (HOD 1998-61; Reaffirmed HOD 2014)

165.962 State Control Over Changes in Health Insurance Coverage and Reimbursement:

MSSNY will seek the enactment of legislation that

(a) requires that physicians receive specific notice of the compensation terms proffered by managed care plans, including a detailed statement of the precise terms by which monies will be paid and

(b) requires that physicians be routinely informed of the method by which the amount of a withhold or a bonus will be calculated, the date upon which payment will be made and a description of the records relied upon to calculate the withhold or bonus and

(c) requires scrutiny of managed care plans financial statements by appropriate state agencies when a managed care plan fails to return funds withheld from physicians in a given year to determine if the retention of funds by the managed care plan is, indeed, justified and

(d) if retention of funds is determined to be unjustified, said agencies direct the managed care plan to return the withhold with appropriate interest and penalties, and

(e) inform beneficiaries when benefits are changed. (HOD 1998-60; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.963 Public Disclosure of Telephone Triage Protocols by MCOs: SUNSET HOD 2014

165.964 Formation of a Special and/or Public Commission to Monitor Managed Care:
SUNSET HOD 2014

165.965 Repeal of ERISA Exemption for HMO Tort Liability:
SUNSET HOD 2014; see 165.968 and 165.969

165.966 Uniform Application Form, Uniform Encounter Form:

MSSNY supports the establishment and use of a uniform application and a uniform encounter form to be used by all HMOs, IPOs, HPOs and IPAs. (HOD 97-273; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.967 Managed Care Organizations to Standardize Pre-Certification:

MSSNY will encourage managed care organizations to standardize pre-certification procedures and time limits for HMOs to respond to pre-certification requests for patient care regardless of the time of day or day of week. (HOD 1997-254; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.968 Liability of Managed Care Entities As Well As Their Employees, Agents, Ostensible Agents And Representatives:

MSSNY will develop or support legislation or regulation requiring that whenever an employee, agent, ostensible agent and/or representative of a managed care entity makes a determination that affects a patient’s health, both the individual and the entity should be held liable for any adverse outcome to the patient arising directly from the determination or as a consequence of the determination. (HOD 1997-114; Reaffirmed HOD 1998-84; Reaffirmed HOD 2014; Reaffirmed HOD 2015-57; Reaffirmed HOD 2020-56; Reaffirmed HOD 2022-61; Reaffirmed HOD 2023-106; Reaffirmed in lieu of resolution 57 – 2024 HOD)

165.969 Managed Care Companies and The Practice Of Medicine Without A License:

MSSNY will support legislation or regulation that will declare that any person making decisions on the medical necessity or appropriateness of care affecting the diagnosis or treatment of a patient in New York must have a license to practice medicine in New York; and that a physician making decisions on the medical necessity or appropriateness of care affecting the diagnosis or treatment of a patient in New York without a valid New York license, as well as the company that employs him/her, will be subject to investigation, criminal prosecution and possible fines. (HOD 1997-112; Reaffirmed HOD 1998-62; Reaffirmed HOD 2014; Reaffirmed HOD 2015-57)

165.970 DEA Numbers Should Not Be Used As A Means Of Physician Identification: SUNSET HOD 2024

165.971 Retrospective Denial of Insurance Claims:

MSSNY will seek legislation which would amend subdivision (4) of section 4903 of the public health law and subdivision (d) of section 4903 of the insurance law which require health maintenance organizations and insurers to “make a utilization review determination involving a health care service which has been delivered within 30 days of receipt of the ‘necessary information’” to further require that in no event shall such determination be made later than 90 days from the submission of the claim. (HOD 1997-97; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.972 Requiring The Use Of Accepted Medical Guidelines By Insurers And Managed Care Entities:

MSSNY will seek legislative or regulatory relief to ensure that insurers and managed care entities use medical guidelines developed by recognized medical specialty societies; such legislation should include provisions that insurers and managed care entities be required to identify and disclose the guidelines being used in specific areas of practice. (HOD 1997-94; Reaffirmed HOD 2003-268 & 278; Reaffirmed HOD 2013; Reaffirmed HOD 2023)

165.973 Patient Access to Physicians No Longer On Plan:

MSSNY will seek legislation which would enable enrollees to a managed care plan to continue to receive care from the enrollee’s current physician for up to one year or the balance of their policy period, whichever is longer, where the physician has left or has been terminated by the plan provided that the termination is not related to imminent harm to patient care, a determination of fraud or a final disciplinary action and provided further that the physician continues to accept reimbursement from the managed care plan at the rates applicable prior to the termination or departure of such physician from the plan and adheres to the plan’s quality assurance and utilization review requirements. (HOD 1997-93; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.974 “Hold Harmless” Protection for Physicians Under Contract:

MSSNY will included in its policies and practices educating the physician on how such “Hold Harmless” clauses can serve to protect the physician or to increase risk exposure. (HOD 1997-79; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.975 Retroactive Denials:

MSSNY working through the Committee on State Legislation will strongly support the introduction of appropriate legislation to require all health insurers in this State, including HMOs, to be precluded from retroactively denying reimbursement to physicians for patients’ admissions to hospitals. (HOD 1997-78; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.976 Substituting Nurse Practitioners For Licensed Primary Care Physicians:

MSSNY will seek legislation prohibiting the substitution of licensed primary care physicians with nurse practitioners, and will continue its public opposition to replacing physicians with physician extenders. In recognition of a patient’s right to receive high quality medical care from appropriately trained health care professionals, and the lack of any credible studies which indicate that services provided by nurse practitioners are equal to those rendered by physicians, MSSNY will communicate to all appropriate state agencies and state officials its opposition to the Oxford Health Plan agreement with Columbia University and Presbyterian Medical Center and to similar activities engaged in by other managed care entities operating in New York State. (HOD 1997-71; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.977 Financial Incentives Based Upon The Non Provision Of Services:

MSSNY will seek legislation which would prohibit the use of any financial incentives which inhibit the provision of medically necessary care. (HOD 1997-68; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.978 Referrals To Allied Health Providers:

It is the position of MSSNY that managed care organizations in the State of New York should be required to designate only MDs and DOs as primary care providers for any individual or group of patients. MSSNY will continue its public opposition to replacing physicians with physician extenders; and will communicate its opposition to the assignment of primary care status to any professional provider other than an MD or DO in managed care entities and workers compensation programs operating in New York State. (HOD 1997-64; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.979 Elimination of the Managed Care Requirement to Obtain a Referral from a Primary Care Physician Prior to Utilizing the Services of a Specialist: SUNSET HOD 2013

165.980 Dismissals for Cause in Managed Care Contracts:

The Medical Society of the State of New York shall seek legislation that no terminations or non-renewals of physician contracts with managed care plans shall be valid without cause, and will seek the introduction of legislation which would require managed care plans to provide all physicians with a fair and equitable due process appeal if they are excluded from a managed care plan regardless of the reasons for such exclusion and irrespective of whether such exclusion is considered to be a termination or a non-renewal. Such due process hearing shall be held before a panel which is composed of three New York State licensed physicians, one of whom is chosen by the plan, one of whom is chosen by the physician who is the subject of the hearing, and the third who is chosen by the other two members of the panel. At this hearing, the physician shall be entitled to be advised of the reason for his de-selection and shall be provided with: (a) the opportunity to be represented by counsel, and (b) the right to call witnesses and present evidence in support of this position. (HOD 1997-53; Reaffirmed HOD 2014)

165.981 Toll-Free Telephone Numbers to be Required for all Health Insurance Carriers to Provide Access for Participating Physicians:

The Medical Society of the State of New York will seek legislation or regulatory action to require PPOs and self-insured plans, as well as insurers not engaged in utilization review procedures, to provide adequate personnel to respond to telephone requests from patients and physicians. These plans should be required to have procedures that; (a) would require that adequate personnel to be available at least 40 hours per week during normal business hours to discuss patient care and allow response to telephone requests; and (b) this telephone system should be accessible on a toll-free basis for patients and physicians; and (c) that there be a toll-free telephone system capable of accepting, recording or providing instruction to incoming telephone calls during other than normal business hours and to ensure that a response to the accepted or recorded message occurs not more than one business day after the date on which the call was received; (d) and that where a plan does not provide for such reasonable and adequate access, the eligibility of a patient with an identification care from the plan will be deemed valid. (HOD 1997-56; Reaffirmed HOD 2000-272; Reaffirmed HOD 2009-259; Reaffirmed HOD 2019)

165.982 Changes in the Bundling of Medical Services by Managed Care Plans:

It is MSSNY’s position that when a patient sees a physician for evaluation and management of an illness, whether primary care or consultation, and the physician also performs a procedure which helps in the diagnosis or treatment of that illness, the physician should be paid for both the evaluation and management code and the procedure code. When a physician sees a patient to perform a pre-scheduled procedure, cognitive services are considered part of the performance of the procedure and the physician should be paid only for the procedure. The supporting rationale for this policy is embodied in two separate functions; (a) the evaluation of the problem and decision to perform a procedure; and (b) the performance and interpretation of the procedure. These functions could often be performed on separate days, but, for reasons of good medicine, expedited care and patient/physician convenience, it is often preferable to perform the procedure on the same day as the evaluation and management visit. It would, therefore, be inappropriate under these circumstances to either unnecessarily require the patient to have the procedure performed on another day or to deprive the physician of equitable payment for the proper provision of both services on the same day. (Council 12/19/96; Reaffirmed HOD 2000-257 & 268; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.983 Redefining the Roles, Obligations and Responsibilities of Insurance Companies which Utilize Capitation as a Means of Physician Reimbursement:

MSSNY will seek legislation requiring managed care organizations to assume appropriate risk while at the same time:

(a) providing an adequate proportion of premium dollars dedicated to medical care;

(b) providing for equitable physician reimbursements;

165.984 Prior Authorization for Procedures Under Managed Care: Limits on Time Requirements:

MSSNY supports the requirement that managed care organizations implement and comply with written procedures to assure that entities that conduct utilization review: (1) provide adequate access to its review staff by a toll-free or collect call phone line, at a minimum, from 8:00 a.m. of each standard business day; (2) establishment of written procedures for receiving or redirecting after-hour calls either in person or by recording; and (3) having a mechanism to receive timely call backs from providers. (HOD 1996-76; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.985 “Hold Harmless” Clauses in Physicians’ Contracts with Health Care Delivery Entities: SUNSET HOD 2014

165.986 Gag Rule in Managed Care Contracts :SUNSET HOD 2014

165.987 Administrative Procedures, Standardization of Managed Care: SUNSET HOD 2014

165.988 Specialty Rosters in Managed Care:

All managed care organizations should be required to maintain full rosters of medical specialists, representing all the specialties approved by the American Board of Medical Specialties and the American Osteopathic Board of Medical Specialties or otherwise provide access outside the managed care organizations to the full range of medical specialists as needed. (HOD 1996-78; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.989 Retrospective Denial of Pre-Certified Services by Managed Care:

The practice of retrospective denial of payment for care which has been pre-certified by an insurer should be banned, except when false or fraudulent information has knowingly been given to the insurer by the physician, hospital or ancillary service provider to obtain pre-certification. (HOD 1996-90; Reaffirmed HOD 2014; Reaffirmed HOD 2016-262; Reaffirmed HOD 2024 – 59)

165.990 Profits and Administrative Costs of Managed Care Organizations: SUNSET HOD 2014

165.991 Responsibility To Patients in Managed Care Plans: SUNSET HOD 2024

165.992 Utilization Review Management:

MSSNY affirms the following position with regard to Utilization Review Management applicable to managed care entities who utilize down-coding, site of service payment reductions, and restrictive patient referral policies as a means of economic disincentives as follows: Physicians who are trained and/or Board Certified in their practice should be allowed to perform and be reimbursed for services if they are medically indicated. Any managed care plan implementing utilization review or management programs should establish an appeals process whereby physicians, other health care providers and patients may challenge policies restricting access to specific services and decisions to deny coverage for services. Such individuals must have the right to have reviewed any coverage denial based on medical necessity by a physician who is of the same specialty and has appropriate expertise and experience in the field. Any physician who makes judgments or recommendations regarding the necessity or appropriateness of services, or site of services, should be licensed to practice medicine and actively practicing in New York State and should be professionally and individually accountable for his or her decisions. The medical protocols and review criteria used by managed care plans in any utilization review or management program must be developed by practicing physicians. Managed care plans should be required to disclose to physicians, on request, the screening and review criteria, weighing elements, and computer algorithms used in the review process, as well as how they were developed. A physician of the same specialty must be involved in any decision by a utilization review or management program to deny or reduce coverage for services based on questions of medical necessity. A physician whose services are being reviewed for medical necessity should be provided the identity and credentials of the reviewing physician on request. The reviewed physician should also have the opportunity to speak with a reviewer. (Council 9/22/95; Reaffirmed HOD 2000-79 & 80; Reaffirmed HOD 13-258; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.993 Emergency Services at Specialty Centers – Equity Coverage by Managed Care Entities:

It is the position of MSSNY that those managed medical care organizations that limit or restrict fiscal coverage to certain hospitals and physicians make an exception for emergent critical care case situations (such as extensive burns, neonatal spinal injuries, multi-organ/extensive trauma) that are sent to the appropriate specialty centers pursuant to guidelines established by organized medicine, and State or Federal policy, rules and regulations. MSSNY strongly opposes any attempt by a managed care entity or third party payer to delay, to deny payments, or to reduce payments when a patient is sent, on an emergent basis, to a designated specialty center and will disseminate this position to the membership and the New York State Health Maintenance Organization Council. (HOD 1994-274; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.994 Policy on Managed Care:

MSSNY affirms the following policy as adopted by the Council on January 23, 1986, and amended by the Committee on Interspecialty on January 13, 1994:

(1) No single pattern of health care delivery is necessarily suited to all patients or to all physicians; and that

(2) The traditional fee-for-service, the HMO, the HMO-IPA, and PPO concepts are valid and acceptable health care delivery systems; but

(3) There must be available multiple delivery mechanisms among which both the patient and the physician can truly exercise the right of free choice of how they will receive and disburse quality medical care; and that

(4) Any managed care plan is urged to cover in its basic policy all medically necessary procedures for all ICD-9 illnesses; medical, surgical, psychiatric and addictive. In the presence of such parity, cost factors may be dealt with by practice parameters, by utilization criteria and review, and by sliding scales of co-insurance and deductibles, not by limiting areas or specialties of care; and that

(5) Employers should contribute equitable amounts for each employee’s health benefit plan, regardless of the plan selected; and that

(6) Fair market competition among all systems of health care delivery shall continue to be MSSNY policy (similar to AMA policy) with the potential growth of health care delivery systems being determined not by governmental intercession or entrepreneurial considerations, but by the number of people who prefer this mode of delivery. In addition, MSSNY recognizes both closed panel plans and open panel plans as valid and acceptable health care delivery modalities, consistent with the foregoing MSSNY policy statement.

MSSNY affirms the following AMA policy statements on managed care encompassing: (1) Case Management; (2) Financial Incentives and Disincentives; (3) Selective Contracting; (4) Physician Governance of Managed Care Program Policies:

1) Case Management (a) Case Management Health plans using the preferred provider concept should not use coverage arrangements which impair the continuity of patient’s care across different treatment settings. (b) With the increased specialization of modern health care, it is advantageous to have one individual with overall responsibility for coordinating the medical care of the patient. The physician is best suited by professional preparation to assume this leadership role. (c) The Primary goal of high-cost management or benefits management programs should be to help to arrange for the services most appropriate to the patient’s needs; cost containment is a legitimate but secondary objective. In developing an alternative treatment plan, the benefits manager should work closely with the patient, attending physician, and other relevant health professionals involved in the patient’s care. (d) Any health plan which makes available a benefits management program for individual patients should not make payment for services contingent upon a patient’s participation in the program or upon adherence to treatment recommendations. (AMA Policy 285.998)

2) Financial Incentives and Disincentives (a) Any financial arrangements that may tend to limit the services offered to patients, or contractual provisions that may restrict referral or treatment options, should be fully disclosed to prospective enrollees by plans utilizing such arrangements. (b) Physicians must disclose any financial inducements or contractual agreements that may tend to limit the diagnostic and therapeutic alternatives that are offered to patients or restrict referral or treatment options. Physicians may satisfy their disclosure obligations by assuring that the managed care plan makes adequate disclosure to patients enrolled in the plan. Physicians must also inform their patients of medically appropriate treatment options regardless of cost or the extent of their coverage. (c) Physicians should have the right to enter into whatever contractual arrangements with health care systems they deem desirable and necessary, but should be aware of the potential for some types of systems to create conflicts of interest because of financial incentives to withhold medically indicated services. Physicians must not allow such financial incentives to influence their judgment of appropriate therapeutic alternatives or deny their patients access to appropriate services based on such inducements. (d) Physician payments that provide an incentive to limit the utilization of services should not link financial rewards with individual treatment decisions over periods of time insufficient to identify patterns of care or expose the physicians to excessive financial risk for services provided by physicians or institutions to whom he or she refers patients for diagnosis or treatment. When risk-sharing arrangements are relied upon to deter excess utilization, physician incentive payments should be based on performance of groups of physicians rather than individual physicians, and should be based over short periods of time. (e) Alternative private health benefit plans, with different schedules of deductibles, coinsurance and premiums, should be available to enrollees so that they are aware of the financial trade-offs associated with different plans. Both private and public third party payment systems should use deductibles and coinsurance as financial incentives for health care recipients to use health care resources in an appropriate manner. However, cost-sharing should not result in an undue financial burden for the health care recipient , and should not act to prevent access to needed care. (f) Physicians, other health professionals, and third party payors through their reimbursement policies, should continue to encourage use of the least expensive care setting in which medical and surgical services can be provided safely and effectively with no detriment to quality. (AMA Policy 285.998)

3) Selective Contracting (a) Health plans or networks should provide public notice within their geographic service areas when applications for participation are being accepted. (AMA 285.998) (b) Physicians should have the right to apply to any health care plan or network in which they desire to participate and to have that application judged on the basis of objective criteria that are available to both applicants and enrollees. (AMA CMS Report B, A-93) (c) Those managed care plans that contract with selected physicians to furnish care should utilize selection criteria based primarily on professional competence and quality of care. Any economic criteria used in such selective contracting should have a demonstrated positive relationship to the quality and appropriateness of care and to professional competency. (AMA Policy 285.997) (d) Managed care plans that contract with selected providers should have an established appeals mechanism by which any provider willing to abide by terms of the plan contract could challenge a decision to deny the provider’s application for participation in the plan. (AMA Policy 285.997) (e) All managed contracts should expressly require the managed care plan to provide meaningful due process protections, in order to prevent wrongful and arbitrary contract terminations that leave the physicians without means of redress. (AMA Policy 285.996) (f) Prior to initiation of actions leading to termination or non-renewal of a physician’s participation contract for any reason, the physician shall be given notice specifying the grounds for termination or non-renewal, a defined process for appeal, and an opportunity to initiate and complete remedial activities except in cases where harm to patients is imminent or an action by a state medical board or other government agency effectively limits the physician’s ability to practice medicine. (AMA CMS Report B, A-43) (g) All “hold harmless” clauses in managed care contracts should be explicitly identified as such. Physicians should consider consulting with legal counsel prior to contracting with a managed care entity to prevent the imposition of unfair liability upon the physician. (AMA Policy 285.995) (h) Physicians should have the right to enter into whatever contractual arrangements with managed care plans they deem desirable and necessary, but should be aware of the potential for some types of plans to create conflicts of interest because of financial incentives to withhold medically indicated services. (AMA Policy 285.998)

4) Physician Governance of Managed Care Programs’ Policies (a) The medical protocols and review criteria used in any utilization review or utilization management programs must be developed by physicians. (AMA Policy 285.998)

In addition it is the position of MSSNY that quality assurance policies and any medical protocols be governed by practicing physicians. Credentialing of physicians is directly related to utilization review and quality assurance, and should, therefore, be operated in accordance with policies determined by physicians. (Council 3/10/94; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

165.995 Organized Medical Staffs in Managed Care Entities:

It is MSSNY policy that managed care entities establish self-governing medical staffs similar, if not identical, to those in hospitals. The principles of self-governance should include, but not be limited to:

the development of medical Staff Bylaws which cannot be unilaterally changed by the governing of managed care entity;
physician selection representatives to the governing board and other appropriate committees of managed care entities including credentialing, privileging, quality assurance and utilization review committees;
due process protections for physicians credentialed by a managed care entity; and full indemnification by managed care entities of physicians who, in good faith, serve as members of credentialing, quality assurance and utilization review committees of managed care entities. (HOD 1994-102; Reaffirmed HOD 2014)

165.996 Personal Financial Gain Should Not Influence Medical Decisions:

It is MSSNY policy that decisions involving medical care should be based upon the medical needs of the patient and independent of physician financial incentives and disincentives. (Council 9/22/94; Reaffirmed HOD 2014)

165.997 Physician Participation in Managed Care Plan:

MSSNY reaffirms current policy on managed care adopted by the Council on March 10, 1994 which is consistent with AMA policy and addresses the right of any physician to seek participation in any health care system. The relevant provisions of this policy read as follows:

(1) Physicians should have the right to join any health care plan or network in which they desire to participate and to have that application judged on the basis of objective criteria that are available to both applicants and enrollees.

(2) Those managed care plans that contract with selected physicians to furnish care should utilize selection criteria based primarily on professional competence and quality of care. Any economic criteria used in such selective contracting should have a demonstrated positive relationship to the quality and appropriateness of care and to professional competency.

(3) Selective contracting decisions made by any health delivery or financing system should be based on an evaluation of multiple criteria related to professional competency, quality of care, and the appropriateness by which medical services are provided. In general, no single criterion should provide the sole basis for selecting, retaining, or excluding a physician from a health delivery or financing system.

MSSNY further espouses the policy that no managed care entity may discriminate against the application of any properly credentialed physician licensed to practice in New York State regardless of board certification status. MSSNY will urge the New York State Department of Health and the New York State Health Maintenance Organization Council to support the MSSNY Managed Care Policy provision which are advanced in the interest of: (1) Continued quality patient care through sustained physician/patient relationships; (2) Equity through the elimination of demeaning, discriminatory, and prejudicial physician enrollment practices and will communicate these principles to all managed care systems doing business in New York State. (HOD 1994-259; Reaffirmed HOD 1996-270, HOD 1997-222 & HOD 2003-100; Reaffirmed HOD 2013; Reaffirmed HOD 2023)

165.998 Point of Service Provision in Managed Care Programs:

MSSNY supports legislation to require all managed care organizations to offer enrollees the option of purchasing coverage for medical care and services provided out-of-network or out-of-plan, and that such option be affordable and provide reasonable payment in order to allow enrollees to seek care outside managed care organization if so desired. (HOD 1994-64; Reaffirmed HOD 1996-58; Reaffirmed HOD 2014; Reaffirmed HOD 2016-60; Reaffirmed HOD in lieu of 2017-61)

165.999 Regionalized Emergency Care Exemption: SUNSET HOD 2014

165.000 MANAGED CARE

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165.000 MANAGED CARE

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