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AMA Passes New Network Adequacy Measures


At its June 2017 meeting, the American Medical Association approved new measures to prevent disruptions in care for patients in active courses of treatment, especially for new enrollees in a health plan. The policy came out of a Council on Medical Service report, which said patients “should also have the opportunity to receive continued transitional care from their treating out of-network physicians and hospitals at in-network cost-sharing levels.”

AMA policy already supports giving patients the opportunity for continued transitional care from physicians who leave their health plan networks or whose health plan contracts are terminated without cause.

“Moving forward, the AMA should continue to provide assistance upon request to state medical associations in support of state legislative and regulatory efforts ... to ensure continuity of care protections for patients in an active course of treatment—both for existing and new health plan enrollees,” the Council wrote.

In addition, delegates approved resolutions on access to out-of-network care. Among the resolutions was an effort by hospital-based physicians and several state medical societies to hold patients harmless from costs associated with unanticipated out-of-network care and ensure incentives for insurers to contract with physicians through fair payments. Proponents said new AMA policy should address the causes of unanticipated out-of-network care as well, including inadequate networks and gaps in insurance coverage.

Under one final measure, the AMA voted to support the following:
  • Patients must not be financially penalized for receiving unanticipated care from an out-of-network provider.
  • Insurers must be transparent and proactive in informing enrollees about all deductibles, co-payments and other out-of-pocket costs that enrollees may incur.
  • The AMA should develop model state legislation to address coverage and payment for out-of-network care.
  • Out of network coverage should be established using geographic data from a benchmarking database that is independently recognized, transparent, verifiable and maintained by a non-profit organization that is not affiliated with an insurer, municipal cooperative health benefit plan or health management organization.
Early in 2017, the AMA said at least, 25 state medical societies anticipate proposals to address out-of-network billing this year, specifically in the hospital-based setting. And in almost as many states, proposals could be introduced to address the adequacy of these networks to offer access to network providers.



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