Issues in National Spotlight

Chicago physicians serve on influential delegation to AMA interim meeting

AS THE House of Medicine took up dozens of resolutions, physicians from the Chicago Medical Society descended on National Harbor, Maryland, to weigh in on white hot issues. But of all the measures to come before the American Medical Association, which held its Interim meeting on Nov. 11-13, several topped the list. This page recaps some of the action. Next month Chicago Medicine will report on other proposals and news from the AMA meeting.

Negligent Credentialing Actions Against Hospitals
In spite of a reference committee’s recommendation not to adopt this resolution, testimony was mixed. Delegates raised several considerations.

Negligent credentialing actions create a roundabout to a medical malpractice lawsuit, allowing plaintiffs to sue a hospital for injuries caused by a physician based on the theory that the hospital granted privileges to that physician when it should not have. Many U.S. courts recognize “negligent credentialing” as a cause of action.

Recently, as noted in one resolution, the Kentucky Supreme Court refused to recognize negligent credentialing as a cause of action because its far-reaching implications are largely unknown.

The threat of liability for negligent credentialing may push hospitals and health plans to adopt more stringent criteria to credential licensed physicians. This would create a significant barrier for physicians, and in effect, harm patient access to care.

The resolution urges the AMA to actively oppose state legislation and court action recognizing “negligent credentialing” as a cause of action that would allow for patients to sue a hospital and medical staff. It further calls for the AMA to advocate for the highest standard of proof (reasonable doubt) on the plaintiff in such claims.
HOD ACTION: Referred for Decision

The Site-of-Service Differential
New AMA policy takes on the issue of site-neutral Medicare payment for outpatient services.

AMA will therefore “support Medicare payments for the same service routinely and safely provided in multiple outpatient settings (physician offices, hospital outpatient departments, and ambulatory surgery centers) that are based on sufficient and accurate data regarding the actual costs of providing the same service in each setting.”

Delegates rejected a proposal that such payments be based on the actual cost of providing services. The delegates also rejected language that site-neutral payments should not be defined as
equal payments or reducing all payments to the lowest amount paid in any setting.

In other action, delegates reaffirmed policies that call for equity of payment between services provided by hospitals on an outpatient basis and similar services in physicians’ offices. Earlier policy also supports defining Medicare services consistently across settings and encouraging the Centers for Medicare and Medicaid Services to adopt payment methodologies that assist in leveling the playing field across all sites of service.

Delegates voted to reaffirm AMA policies that encourage CMS to expand the extent and amount of reimbursement for procedures performed in the physician office, to shift more procedures from the hospital to the office setting... and direct the AMA to aggressively promote the compilation of accurate data on all components of physician practice costs.
HOD ACTION: Adopted as Amended.

Prior Authorization Relief
Updated AMA policy recommends the following processes and parameters to prior authorization programs for Medicare Advantage plans, Medicaid and Medicaid managed care plans:
• List services and prescription medications that require prior authorization on a website and ensure that patient informational materials include full disclosure of any prior authorization requirements.
• Notify providers of any changes to prior authorization requirements at least 45 days prior to change.
• Improve transparency by requiring plans to report on the scope of prior authorization practices, including the list of services and prescription medications subject to prior authorization and corresponding denial, delay, and approval rates.
• Standardize a prior authorization request form.
• Minimize prior authorization requirements as much as possible within each plan and eliminate the application of prior authorization to services and prescription medications that are routinely approved.
• Pay for services and prescription medications for which prior authorization that has been approved unless fraudulently obtained or ineligible at time of service.
• Allow continuation of medications already being prescribed when a patient changes health plans; any changes must be approved by the ordering physician.
• Provide an accessible and responsive direct communication tool to resolve disagreements between health plan and ordering provider.
HOD ACTION: Adopted as Amended.