SUGGESTED BOARD ACTIONS

RECOMMENDATION 1:

The Board of Trustees decided that PAMED Policy 185.992 Denials by Insurers be amended as follows:

• 185.992 Denials by Insurers – PAMED shall:

1. Work in cooperation with the Pennsylvania chapter of the American College of Emergency Physicians to resolve issues associated with payment for emergency care.
2. Educate physicians, physicians’ staff, and patients on how to access and effectively utilize insurer grievance mechanisms, to dispute coverage decisions made by insurers.
3. Continue efforts to enact legislation requiring insurers to coverage limitations and exclusions to purchasers and patients.
4. Educate employers who have experience-rated benefit plans about how to interpret their utilization data to determine if they provide adequate coverage.
5. Work with the media and various entities to educate the public about how the definition of medical necessity can vary and about how insurers influence their treatment as a result of these varying interpretations.
6. Take appropriate action requiring insurers to disclose to the public the clinical guidelines and other criteria (“Black Box Algorithms”) they utilize to determine if a service is medically necessary.
7. Advocate that (a) that all denials of care resulting from precertification and concurrent utilization review be performed by licensed physicians. (Medical Doctors and Doctors of Osteopathy); and (b) that all retrospective utilization reviews resulting in denials on the grounds of medical necessity and all appeals be performed by physicians licensed by the Commonwealth who are in active clinical practice (defined as an average of at least 20 hours per week in the treatment of patients; in the same specialty as the practitioner under review or of the specialty which normally managed the form of care under review). ; and (c) for legislation in Pennsylvania to protect physicians’ ongoing utilization of artificial intelligence (AI) tools in prior authorization appeals and their ability to provide timely care to patients.
8. Promote the tenet that when payment is denied by an insurer because the services are deemed “not medically necessary”, this equates to a clinical decision made by the insurer about what health care services are medically necessary.
9. Promote statements from the American Medical Association’s Code of Medical Ethics related to the allocation of limited resources (E-2.03) such as, “A physician has a duty to do all that he or she can for the benefit of the individual patient” and “Physicians have a responsibility to participate and to contribute their professional expertise in order to safeguard the interests of patients in decisions made at the social level regarding the allocation or rationing of health resources.”
10. Review various issues associated with requiring insurers to maintain a record of all payment denials based on the determination that the care was not medically necessary and with disclosing this information to the public. (Report 13, Board of Trustees, H-1997)

RECOMMENDATION 2:

The Board of Trustees decided that amended PAMED Policy 185.992 Denials by Insurers be adopted in lieu of Resolution 25-408.