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Retrospective Payment Denial and Teen Health: PA Physicians Take Action

At a Glance

  • Concerns about retrospective payment denial of medically appropriate studies, procedures, and testing were addressed by the PA delegation during the interim session of the American Medical Association's House of Delegates (AMA HOD) held Nov. 12-15, 2016. The AMA will study the issue further.

  • Teen Health Week will be actively promoted by the AMA in 2017. Delegates voted to approve this resolution sponsored by the Pennsylvania delegation.


 

While Maintenance of Certification (MOC) was a major focus of the PA Delegation at the recent interim session of the AMA HOD—Learn more about their MOC efforts here—they also led the conversation on several other health care issues.

Physician delegates from across the nation considered PA delegation resolutions on teen health and retrospective payment denial. Both resolutions originated at the Pennsylvania Medical Society House of Delegates (PAMED HOD) meeting held on Oct. 22-23, 2016. James Goodyear, MD, of Montgomery County and a past president of PAMED, is chair of the PA Delegation to the AMA that carried these resolutions to the AMA level.  

Retrospective Payment Denial of Medically Appropriate Studies, Procedures, and Testing

A PA Delegation resolution concerning retrospective payment denial of medically appropriate studies, procedures, and testing was referred to the AMA Board of Trustees for study. The AMA HOD will provide a report on the issue when it reconvenes at its June annual meeting. 

The resolution asked the AMA to advocate for legislation to:

  • Require insurers' medical policies to reflect current evidence-based medically appropriate studies and treatments, including those for rare and uncommon diseases.
  • Require insurers to implement a streamlined process for exceptions for rare or uncommon disease states.
  • Prohibit insurers from using medical coding as the sole justification to deny medical services and diagnostic or therapeutic testing. 

The original resolution regarding retrospective payment denial was adopted by the PAMED HOD and was introduced and authored by Gwendolyn Poles, DO, of the Dauphin County Medical Society.

Find out more about a recent Pennsylvania law that limits retroactive denials by insurers here.

Teen Health Week

The AMA HOD adopted a Pennsylvania Delegation resolution which calls on the AMA to actively promote Teen Health Week in 2017. Current AMA policy supports the involvement of medical students, residents, and other physicians in education efforts to enhance teen health. 

The original resolution—adopted by the PAMED HOD in October 2016—was authored by Laura Offutt and the Delaware County Medical Society Board of Directors, as well as Michael DellaVecchia, MD, and the Philadelphia County Medical Society Board of Directors. It also calls for PAMED to actively promote Teen Health Week and encourage state, county, and specialty society medical associations to join with local schools to adopt, promote, and participate in the event.

Pennsylvania's Teen Health Week is focused on nutrition and fitness, violence prevention, mental health, sexual health, and substance abuse. The upcoming Teen Health Week will be held on Jan. 9 – 13, 2017. Learn more about Pennsylvania's Teen Health Week here and access a PA Teen Health Week Toolkit.

"Pennsylvania Teen Health Week, a week focused specifically on the important topic of holistic health in teenagers, calls upon teens and adults in our communities and in our health care and educational institutions to focus on the health needs of this special population," says Dr. Offutt. "Since adolescents often are agents of change, including them in discussions and really listening to what they have to say about improving their own health behaviors is critical." 

More Resources

Get more details from PAMED on:

  • Maintenance of Certification—To find out more about PAMED's ongoing role as the national leader in the fight to ensure a fairer MOC process, visit www.pamedsoc.org/moc.   
  • Health care issues addressed by the PAMED House of Delegates in October 2016—Check out PAMED's overview of the meeting at www.pamedsoc.org/HODrecap.

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