American College of Physicians: Internal Medicine — Doctors for Adults ®

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College speaks up for practicing internists in meetings with health plan executives

From the November 2000 ACP-ASIM Observer, copyright © 2000 by the American College of Physicians-American Society of Internal Medicine.

By Phyllis Maguire

The College this summer met with executives from insurers and managed care trade organizations to discuss issues that concern internists like delayed payment, the use of all-products clauses and access to eligibility data.

In June, the College's Medical Services Committee met with physician leaders from Blue Cross Blue Shield plans to discuss these concerns. (Individual Blue Cross Blue Shield plans are also arranging meetings with College chapters to address these issues.) And in July, College leaders met with representatives from Cigna Healthcare and from two trade organizations, the American Association of Health Plans and the Health Insurance Association of America.

Cecil B. Wilson, FACP, a College Regent and Chair of the Medical Services Committee, said he views the meetings as a sign that the industry is finally responding to what he called "an increasing drumbeat of opposition" from the public, the media and national and state legislatures.

While some skeptics have said industry efforts like this year's formation of the Coalition for Affordable Quality Healthcare (CAQH) are little more than a ploy to polish managed care's tarnished image, Dr. Wilson said the College plans to take advantage of any opening to advocate on behalf of internists. "The fact is the industry is coming to the table," he said. "We look forward to seeing tangible results."

Here are some of the issues the College discussed during its meetings with Blue Cross Blue Shield and Cigna:

  • Claims payment. The College objects to policies that inappropriately deny claims, delay claims processing and payment and rely on "black box edits" (using software to automatically downcode claims).
  • All-products clauses. The College objects to contracts that force physicians to participate in all of a health plan's products against their will.
  • Eligibility and preauthorizations. The College wants health plans to give physicians easy 24-hour access to eligibility data and preauthorization systems.
  • Defining medical necessity. The College wants insurers to work with organized medicine to develop a single medical necessity standard.
  • Simplified administration. The College wants the industry to develop credentialing and site visit standards, as well as a uniform health insurance form.
  • Formularies. The College is concerned that the many variations and changes in plan formularies make physician compliance difficult.

College representatives also joined leaders from other medical organizations in meetings with the Health Insurance Association of America and the American Association of Health Plans. Both groups have asked the College and other specialty societies to form workgroups with executives and hold roundtable discussions at industry meetings to improve relations between the managed care industry and physicians.

Dr. Wilson said that the College welcomes the opportunities to open a dialogue with health plan officials, but he added that ACP­ASIM will continue to push for legal solutions such as patient protection legislation. "The problems associated with managed care require more than just companies' voluntary changes," Dr. Wilson said. "Some real legal protection is also needed."

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