Take two tablets and call me in the morning.
The AMA has released its “Health Insurer Code of Conduct Principles.” There are 10 of them, but let’s focus on #5: “Medical Necessity.” Here’s what the AMA has to say:
Medical care is “necessary” when a prudent physician would provide it to a patient for the purpose of preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate in terms of type, frequency, extent, site and duration; and (c) not primarily for the economic benefit of the health plans and purchasers or the convenience of the patient, treating physician, or other health care provider.
And further do
Health insurers must not use financial incentives that discourage the rendering, recommending, prescribing of, or referral for medically necessary care.
And finally:
No care may be denied on the grounds that it is not “medically necessary” except by a physician qualified by education, training and expertise to evaluate the specific clinical issues.
“Health insurers should provide access to necessary health care, protect the patient-physician relationship and accurately process medical claims, but too often they are an obstacle,” said AMA President J. James Rohack, M.D. “The new Health Insurer Code of Conduct Principles will help protect patients and physicians from questionable insurance practices by holding the health insurance industry accountable.”
The AMA’s full statement along with a link to their new 10 Commandments can be found here.
And, let’s not forget who the nation’s biggest health insurer is – that’s right, Uncle Sam.
