Position Statements (100.00 – 199.99)


100.000       FAMILY AND MEDICAL LEAVE:  (See also Hospitals, 150.000)

100.999       Family and Medical Leave
                     SUNSET HOD 2014

105.000       GENETICS:

105.997        Genomic Medicine

The Medical Society of the State of New York will encourage further research into genomic sequencing, including its ethical, clinical and financial implications, and will also encourage efforts to increase the number of qualified genetic counselors in anticipation of the increasing clinical need. (HOD 2015-268, referred to, amended and adopted by Council 1/21/2016)

105.998           Discrimination, Prevention of Selective in Insurance Plans

MSSNY will introduce or support legislation to forbid insurance companies from using as criteria for issuance of coverage or premium rating for health, life and disability policies information derived from genetic screening.  (HOD 1996-172; Reaffirmed HOD 2014)

105.999           Preconception/Prenatal Counseling

The physician has a responsibility to inform the pre-conception/prenatal patient/couple of the risk of possible genetic defects when the patient is at risk because of age, previous obstetrical history, maternal/paternal family history, or exposure to predisposing factors; to advise the patient/couple of the availability of genetic counseling types of diagnostic procedures, and the related risks involved; or the physician may refer the patient to the appropriate counselor or facility.  Physician responsibility should be based on the standard of medical practice and the methods of procedures prevailing at the time of counseling.    (Council 5/17/79; Modified and Reaffirmed HOD 2013)

110.000          HEALTH CARE DELIVERY SYSTEMS:
                       (See also Health System Reform, 130.000; Managed Care, 165.000) 

110.984           New Review of For-Profit-Health Insurance by Institute of Medicine

MSSNY will ask the Institute of Medicine to report again on the for-profit enterprise in health care. (HOD 2016-109)

 110.985           Employed Physicians

MSSNY will examine governance structures of hospitals, physician group practices, federally qualified health centers, clinics, urgent care practices and other health care delivery facilities and physician employment contracts to determine the most effective way to provide a grievance mechanism to resolve disputes between physicians and their employers. (HOD 2016-102) 

110.986           Monopolization of Healthcare by Vertically Integrated Health Systems

The Medical Society of the State of New York will seek legislation and regulation that vertically integrated hospital systems must prove to the Department of Health a need to employ an individual physician in the market place and obtain a Certificate of Need for each of their employed physician.  The Certificate of Need process should include an evaluation of the employment agreement, insofar as it be limited to fair market values of physician services and not to include ancillary services.  (HOD 2015-117; referred to and adopted by Council 11/5/2015) 

110.987           Collaborating with Federal and State Agencies to Ensure the Provision of Long Term Care Services

Through its Long Term Care Subcommittee of the Quality Improvement and Patient Safety Committee, MSSNY will work with all relevant federal and state agencies to ensure that long term care services, including home care services, physician home visits, telehealth and palliative care, are integrated into and paid for through new initiatives underway which seek to restructure the health care delivery system, such as the Delivery System Reform Incentive Payment (DSRIP) Program, Medicare Shared Savings Accountable Care Organizations and the Fully-Integrated Dual Advantage (FIDA) Program. (HOD 2015-107) 

110.988           Too Big to Fail

The Medical Society of the State of New York will work with the New York State Department of Financial Services and New York State Department of Health to assure large health care systems across New York State are adequately capitalized to withstand economic adversity when those systems take on financial risk contracts with insurers or offer health insurance coverage.  (HOD 2015-67) 

110.989           Long Term Care-Scope of Problem

The Medical Society of the State of New York (MSSNY) will urge the New York State Department of Financial Services to develop an educational program on long term health care financing and MSSNY will request that the New York State Department of Financial Services promote and make this program available to all New Yorkers. (HOD 2014-165) 

110.990           PCORI Should Focus on Clinical Outcomes Not Cost

The Medical Society of the State of New York supports efforts by the American Medical Association to have the Patient Centered Outcomes Research Institute (PCORI) focus its priorities on achieving better clinical health outcomes. (HOD 2012-65)

110.991           Web-based Tele-Health Initiatives and Possible Interference with the Traditional Physician-Patient Relationship

The Medical Society of the State of New York (MSSNY) urges the NYS Department of Financial Services and Department of Health, to review tele-health initiatives being implemented by major health insurance carriers (i.e., United Healthcare, Blue Cross Blue Shield) and others to assure that proper standards of care are maintained, that such initiatives and the physicians who work with them are adherent to professional practice standards and NY State health laws and regulations; and to take appropriate actions to eliminate such initiatives that do not meet acceptable standards and regulations.

The Medical Society of the State of New York (MSSNY) will seek regulatory guidance from the NY State Department of Financial Services regarding the essential requirements of web-based tele-health technology and health care initiatives and the requirements of physicians and healthcare providers who engage in the delivery of such services. 

Concerns about tele-health initiatives and this resolution are to be brought by the MSSNY AMA delegation to the AMA for appropriate action at the Federal level. (HOD 2012-165)

110.992           Standardization of Identification for Medical Professionals

MSSNY will work with appropriate health care entities to assure (ensure?)  that licensed physicians and other health care practitioners wear a picture identification badge which shall be conspicuously displayed and legible, and which clearly details to the patient, the name and professional title authorized pursuant to Education Law (Physician, Physician Assistant, Nurse Practitioner, etc) of their physician and any other health care practitioner’s.

Any picture identification badge for physicians and other health care practitioners should be provided at no cost to the physician and health care provider. ( HOD 2012-105)

110.993           Ionizing Radiation from Fluoroscopy Concerns:

MSSNY, in collaboration with The College of Radiology and with advice of legal counsel, will clarify the scope of practice and delineation of privileges regarding the performance of fluoroscopy by physician extenders under direct physician supervision.  (HOD 2009-150)

110.994           Health Care Reform Based Upon Evidence Not Ideology:

In recognition that the current health care delivery system model has proven ineffective at the goals of cost containment, improved access, and improved outcomes, MSSNY should actively engage in pursuit of a new health care delivery system model that is primarily based upon evidence which supports these stated objectives, and not reforms based just upon political or economic ideology.  (HOD 2007-103)

110.995           Appropriate Disclosure by Nurse Practitioners of Collaborating and Coverage Agreement & Scope of Practice:

MSSNY should advocate for:

(1)        the enforcement of Nursing Education Law 139 stipulating that the collaborating physician(s) be prominently posted;

(2)        extension of this ordinance to include the posting of collaborating physician(s) in all advertising, stationery, business cards, etc.;

(3)        the inclusion of not only the collaborating physician(s) but also all coverage agreements including off hours and emergency in patient areas;

(4)        Medical Society of the State of New York advocate for the principle that, regardless of any previous specialty training or expertise on the part of the extender(s), the scope of their practice be limited to and be congruent with that of their current collaborating physician(s); and

(5)        assurances that any off hours and emergent covering arrangements be consistent with the extender(s) current scope of practice and expertise so as to ensure no gaps in care are incurred by the patient.  (HOD 2007-99)

110.996           Oral Maxillofacial Surgery Scope of Practice:

MSSNY should oppose any and all legislation to expand the dental scope of practice to allow non-physicians to perform plastic facial rejuvenation and reconstructive surgery of the oral and maxillofacial area that is not directly related to restoring and maintaining dental health.  (HOD 2007-98)

110.997           The Need for Patients to be Informed as to the Difference Between Physicians and other Types of Health Care Providers so as to Allow the Patient to Make a Choice of a Physician or Other Health Care Provider Based on Informed Consent:

MSSNY will seek State and Federal legislation mandating that patients be notified whenever a health care provider other than a physician will provide care to a patient.  (HOD 1998-57; Reaffirmed HOD 1999-83; Reaffirmed HOD 2014)

110.998           Non-physician Practitioners in Today’s Health Care Delivery Systems:

(A)  Scope of Practice:  While the Medical Society is certainly concerned about system costs, our primary focus is and must be on quality.  We believe, therefore, that non-physician professionals should be used in a manner commensurate with their training.  It is clear, furthermore, that how we pay non-physician practitioners will directly affect how they practice.  The medical community firmly believes that non-physician practitioners lack the education and training necessary to practice independently of physicians.  A serious danger to the well-being of the citizens of this state will result if health care professionals, competent within their own fields, are permitted to work in areas beyond their competence and training and/or without an appropriate relationship with a physician.  Moreover, to the extent that some advocate the expansion of the services performed by non-physician practitioners in the pursuit of system economies, but without an adequate educational base, costs will inevitably increase, not decrease.  Therefore, while the Medical Society is committed to ensuring the efficient and responsible integration of these professionals into health care delivery teams, we should be moving toward an integrated system, not reversing statutorily created interrelationships which foster cohesion in our health delivery processes rather than fragmentation.  Consequently, MSSNY strongly opposes any expansion of the scope of practice of non-physician practitioners which would undermine the quality of health care and compromise public safety.

(B)  Practice Setting and Distribution:  Certain interests recommend increasing the number of non-physician practitioners to address perceived provider shortages in underserved areas of the state.  MSSNY, for a variety of reasons, questions the reasonableness of this conclusion.  Generally, it is difficult to entice physicians to practice in such locations where they must be on call constantly, have few professional colleagues with whom to interact and where their spouses may not be able to find suitable jobs in such settings.  Non-physician practitioners face similar, If not the same disadvantages.  Furthermore, government should always be alert to initiatives which could result in the establishment of a two-tiered system of health care and, in effect, deny physician services to the elderly, poor and chronically ill.  In light of the efforts of managed care organizations to significantly constrict staffing levels, and in view of the persuasiveness of managed care in New York State, we submit that government should carefully examine future work force requirements generally.

(C)  Manner and Extent of Compensation:  In certain government forums, non-physician practitioners are advocating that they should receive the same amount of compensation paid to physicians for certain services.  MSSNY specifically opposes any policy which would implement “parity” of payment between physician and non-physician providers.  MSSNY supports the implementation of a differential payment structure based upon the provider’s level of training, skill, expertise, responsibility and practice costs.  Such a payment structure must necessarily recognize the inherent distinctions which exist between the extent of physician education and training as compared to that of non-physicians.  Such distinctions in education, training, legal recognition and scope of practice demonstrate beyond argument the lack of any “equivalency” of service despite the claims by some non-physician practitioners.  As noted above, the education of a nurse practitioner can be completed in as few as thirty-one months consisting of two years of junior college and nine months of advanced nurse practitioner certification program, or in as much as six years including four years of college and two years in a combined masters and certificate training program.  By contrast, generalist physicians have at least eleven years of education and training, including four years of college, four years of medical school, three years of residency and often, additional years of fellowship training. A differential payment structure which recognizes and compensates those with greater skill, knowledge and training is absolutely necessary to assure that dedicated, talented and intelligent individuals are attracted to the profession of medicine.  Obviously, young women and men are motivated to pursue the long and arduous work of medical licensure for a variety of reasons, not the least of which is the unique opportunities which the profession offers to serve society in a very direct and personal way.  However, we must also recognize the necessity of fair and adequate compensation for those who pursue this course.  Without such a structure, there would be inadequate training required of physicians today.

MSSNY strongly supports the provision of payment to a physician for all services provided by non-physician practitioners under the physician’s supervision and direction regardless of whether such services are performed when the physician is physically present, so long as the ultimate responsibility for such services rests with the physician.  Such a payment relationship is completely consistent with the functional relationships required by NY law which clearly prescribe that the physician is ultimately responsible for services provided by nurse practitioners and certified nurse midwives with whom the physician is collaborating, and physician assistants who the physician is supervising.  As a result, MSSNY opposes direct reimbursement to non-physician practitioners.  (Council 1/19/95; Reaffirmed HOD 2014)

110.999           Primary Care Services, Access to

It is the position of MSSNY that a patient’s access to primary care services provided by a physician should not be limited by the specialty or subspecialty designation of the physician, but should be determined by the training, competence, and experience of the physician to provide primary care services, and that health plans should allow physicians with the appropriate qualifications to elect to provide primary, specialty and subspecialty care services.  (Council 12/15/94; Reaffirmed HOD 2014)

115.000      HEALTH CARE PROFESSIONALS/PROVIDERS: (See also Acquired Immunodeficiency
Syndrome [AIDS], 15.000)

115.985           Repeal Prohibition on Pathologist/Patient Interaction

The Medical Society of the State of New York supports the efforts of the NYS Pathology Association to seek a repeal of the New York State regulation which prohibits pathologists from speaking directly to patients about test results. (Adopted, Council June 2, 2016) 

115.986           Laymen’s Medical Advice Policy

MSSNY will ask the AMA to support a public campaign which will promote patient recognition that when seeking medical advice, they are best served through partnership with their personal physician.  (HOD 2016-212)

115.987:          Healthcare Provider Representation and Patient Protection

MSSNY endorses the enactment of legislation that would establish requirements for all licensed health care providers who deliver direct care in an Article 28 licensed hospital, ambulatory surgical center, diagnostic and treatment center, or private physician’s office that is accredited (OB), to wear identification badges that in addition to current State Education Department identification requirements, also contain large bold lettering indicating the practitioner’s licensure (i.e. PHYSICIAN, RN, NP, PA, etc.). (HOD 2013-113)

115.988:          Physician Extender Payment *

MSSNY should lobby our state legislators and congressional delegation for an increase in physician payment commensurate with training, experience and responsibility, so that physicians who collaborate with or supervise physician extenders are paid for this role because of the increased expertise they must provide and responsibility they must accept. Also, the MSSNY delegation to the AMA should bring to the AMA a similar resolution for immediate and high priority legislative action.  (HOD 2013-111) * Title and Resolves amended to reflect the will of House to use the term ‘payment’ or ‘paid’ in lieu of terms ‘reimbursement’ or ‘reimbursed.

115.989        Physician Surrogates:

MSSNY to urge the American Medical Association to examine programs developed by government or managed care organizations where physician extenders practice independently and insist that there be Level 1 evidence to demonstrate that there is no diminution in the quality of patient care by programs that use non-physician providers.  (HOD 2011-114)

115.990           Simplifying the Credentialing of Teleradiologists:

MSSNY to work with the Healthcare Association of New York State (HANYS) to devise and implement a method to expedite the hospital credentialing of physicians providing teleradiology  services, including if necessary legislation or regulation, to reduce the unnecessary duplication of having to meet credentialing requirements for multiple hospitals.  (Council 11/19/2009)

115.991            Limiting the Scope of Practice of Specialists Assistants in Radiology:

That MSSNY support the efforts of the NYS Radiological Society and the American College of Radiology to obtain regulation which would preclude a Specialist Assistant in Radiology from rendering an official report of any image produced by any diagnostic imaging technique and that a similar resolution be forwarded to the American Medical Association at the 2006 Annual Meeting.  (HOD 2006-87; Reaffirmed HOD 2016)

115.992           To Mandate Registered Professional Nurses in Schools:

MSSNY encourage the availability of nurses so that every public and private school has a registered professional nurse with the appropriate skills, education, and training, in every school in a ratio consistent with the National School Nurse Association recommendation, but not less than one registered nurse immediately accessible in person for an emergency.  (HOD 2006-165; Reaffirmed HOD 2016)

115.993           Scopes of Practice of Physician Extenders:

MSSNY supports the formulation of more clear definitions of scopes of practice of physician extenders to include more direct physician responsibility in their supervision and limits of numbers of visits by physician extenders allowed between cooperating physician visits with their patients.

MSSNY will embark on a campaign to remind physicians of the importance and responsibility of maintaining regular contact with all of their patients particularly when physician extenders are involved.  (HOD 2002-66; Reaffirmed HOD 2013)

115.994           Certified Medical Assistants/Medical Assistants – Preservation of Physician Autonomy in
                          Employment and Assignment of Duties

MSSNY will develop and promote regulation and/or legislation that allows Certified Medical Assistants and Medical Assistants to continue to perform the usual duties of their position under the direct supervision of their physician employers if the physician has evaluated and approved their ability to do so, making this a part of the Annual Legislative Agenda until this goal has been attained.  (HOD 1996-68; Reaffirmed HOD 2014)

115.995           Education Programs for NursesSUNSET HOD 2013

115.996           Shortages of Nursing and Other Health Care Personnel:

MSSNY is working with the Legislature to implement short and long range measures to address nursing and other health care personnel shortages such as:  (1)  Using New York State funds earmarked for hospital implementation of the revised minimum hospital code to provide labor rate relief for nursing and other health care personnel;  (2)  Providing hospital reimbursement sufficient to allow hospitals to provide adequate salaries for nursing and other health care personnel;  (3)  Encouraging development of salary and career ladders in nursing that relate experience and increased responsibility to salary;  (4)  Developing and increasing efforts to educate and retain professional health care workers;  (5)  Developing efforts to increase and retain personnel beginning with junior and senior high students, and that include scholarship programs and expansion of loan forgiveness programs.

MSSNY is identifying additional measures that it can support to address these problems surrounding health care personnel shortages.

MSSNY has strongly encouraged the New York State Department of Health to establish a Hepatitis B Vaccination program for high risk health care workers in New York State and is seeking support from the Hospital Association of New York State (HANYS) for a joint effort to achieve changes in State regulation and/or legislation to obtain State funding so that such vaccinations can be provided free of charge to any health care worker at high risk.  (HOD 1988-51; Reaffirmed HOD 2013)

115.997           Hepatitis B Immunization: SUNSET HOD 2014

115.998           Nurse Practitioners – Independent Practitioners

MSSNY opposes legislation which would permit nurse practitioners to practice without a written practice agreement and collaborative relationship with a physician.  (Council 4/22/82; Modified and reaffirmed HOD 2013)

115.999           Nursing and Medical Practice, Distinction Between

MSSNY opposes legislation which would increase the scope of nursing practice so as to blur the distinction between nursing and medical practice.  (Council 3/23/78; Reaffirmed HOD 2013)

117.000      HEALTH INFORMATION TECHNOLOGY: (See Managed Care, 165.000; Medicare, 195.000) 

117.975           Recommendations of White Paper:  Improve EHR Satisfaction

MSSNY adopts the following recommendations to improve implementation and satisfaction among users of Electronic Health Records (EHR)

  1. Improve design and workflow so that EHR:
  2. doesn’t take away time spent with patients
  3. does not interfere with doctor-patient relationship and
  4. reduces total time spent on EHR per patient
  5. Workflow should be customizable not only to fulfill various needs of different specialties,

but to accommodate needs of every individual physician as well.

  1. Reduce documentation that serves functions other than care of patients, and reconsider

incentives and penalties.

  1. Reduce cost of EHR
  2. EHR should help generate necessary billing reports and allow e-prescription of

medications

  1. EHR should prompt physicians about gaps in care of their patients and also help with

clinical decision support.

  1. Improve interoperability between physicians and all healthcare providers. Peer to peer            exchange should be the goal whether it’s direct or through an exchange.
  2. Improve value of notes in telling the patient’s story and the thought process of the physician rather than the volume of data.
  3. EHR should capture episodes of care rather than encounters.

(Adopted, Council April 17, 2016; Full white paper available upon request)

117.976           Electronic Health Records, a Failure of Health Care Reform

The Medical Society of the State of New York (MSSNY) will urge the American Medical Association (AMA) to research the failure of Electronic Health Records (EHRs) to achieve their stated goals and to ascertain the validity, value and accuracy of various EHRs.  MSSNY and the AMA should urge payers to issue a moratorium on penalties for those that do not utilize EHRs since they have not evolved adequately.

It shall be the policy of MSSNY that public and private insurers should not require the use of electronic medical records.  (HOD 2016-111) 

117.977           Quality Improvement in Clinical/Population Health Information Systems

The Medical Society of the State of New York will request that the American Medical Association invite other expert physician associations into the AMA consortium to further the quality improvement of electronic health records (EHR’s) and Population Health as discussed in the consortium letter of January 21, 2015 to the National Coordinator of Health Information Technology.

MSSNY will support efforts by the AMA to secure specific changes to the EHR certification process which will enhance security of information contained in an EHR, prioritize functionality testing, decouple EHR certification from the meaningful use program and support greater standardization and greater transparency of standards which support interoperability of EHR’s.  (HOD 2015-105) 

117.978           Meaningful Use Requirements

The Medical Society of the State of New York will work with the American Medical Association to ensure that the Centers for Medicare & Medicaid Services and the National Coordinator for Health Information Technology: (1) adopt a more flexible approach for meeting Meaningful Use; (2) expand hardship exemptions for all meaningful use stages; (3) improve quality reporting; and (4) address physician electronic health record usability and interoperability.  (HOD 2015-104)

117.979           Scheduled Medications

MSSNY will work with New York State to improve the I-STOP program by including a link to patient prescription histories which will appear at the time of prescribing as well as at the pharmacy where said prescription is filled. (HOD 2015-101; Reaffirmed HOD 2016-112 & 113) 

117.980           Shared Savings and I-STOP

The Medical Society of the State of New York will urge the New York State Department of Health and Department of Financial Services to require health insurers to identify cost savings they have experienced as a result of compliance with the I-STOP law, and that the savings accrued through the use of the I-STOP law be directed toward the development and distribution of electronic medical records (EMR) and electronic prescribing resources which are to be made available to active MSSNY members for use in electronic prescribing and the development of a secure central prescription registry. (HOD 2015-59) 

117.981           Patient Consent for Uploading Patient Records to the SHINY-NY And RHIOs

The Medical Society of the State of New York (MSSNY) will seek legislation or regulation that requires patient consent for uploading patient records to Regional Health Information Organizations (RHIOs) and the Statewide Health Information Network of New York (SHINY-NY).

The MSSNY will seek legislation or regulation to tighten access to patient records so as to restrict access without patient consent, ie “break the glass,” only when the patient is not in a conscious or rational state of mind or their legal representative is unable to provide consent and the healthcare provider documents the life-threatening reason for having to access the patient record.

MSSNY will seek to educate patients and patient advocacy organizations concerning the data contained within the SHIN-NY database. (Amended and adopted Council 11/20/2014; from HOD 2014-105) 

117.982           Exemption Criteria for Electronic Health Record Adoption and Cloud-Based Electronic Health Record Packages

The Medical Society of the State of New York will ask that the American Medical Association (AMA) not give up the fight for Electronic Health Records (EHR) exemptions and continue to petition the Centers for Medicare and Medicaid Services (CMS) to:

(a)  Grant solo physician practices and physicians nearing the age of retirement an exemption from the disincentives associated with not using Electronic Health Records (EHR); and

(b)  Provide government EHR adoption subsidies for any small and/or solo physician practices that demonstrate a need for these subsidies, beyond the present incentive payment structure; and

(c)  Provide cheaper alternatives to commercial EHR systems, either through a lowest-bid Request for Proposal (RFP) process with commercial vendors, or the development of a low-cost or free, CMS-based and administered, cloud-based system for physicians in solo practice and physicians nearing the age of retirement.

The Medical Society of the State of New York will urge the American Medical Association (AMA) request the Centers for Medicare and Medicaid Services (CMS) grant a “temporary waiver” for physician practices that are, in good faith, in the process of obtaining and attempting to implement meaningful use of an Electronic Health Records system, but due to technical issues beyond their control will be unable to meet the October, 2014 attestation deadline. (HOD 2014-107) 

117.983:          Quality of Care, Not Cost, Must be the Criterion Used in Online Patient                      Searches for Physicians

MSSNY should seek legislation requiring health plans in New York State that offer online physician rankings to include, as part of their rankings, quality criteria such as following quality of care guidelines and evidence-based protocols, as well as treatment outcome and patient satisfaction criteria, as well as legislation prohibiting health plans in New York State from limiting patient searches for physicians by specialty solely to those physicians who meet the plan’s cost criteria. (HOD 2013-267)

117.984:          Electronic Health Record Problems

MSSNY will work with New York’s congressional delegation, as well as encourage the AMA to work proactively with MSSNY, to assure that additional federal financial incentives are provided to encourage physicians to adopt HER, and to assure that physicians who use cloud based electronic health record systems are indemnified for security breaches caused by defects in such systems. (HOD 2013-105) 

117.985:          EHR Standardization

MSSNY will seek legislation or regulation to require all EHR vendors in New York State to utilize standard and interoperable software technology components to enable cost efficient use of electronic health records across all health care delivery systems, including institutional and community based settings of care delivery, and will transmit a copy of this resolution to the AMA for consideration at its next House of Delegates meeting. (HOD 2013-104; Reaffirmed HOD 2016-112 & 114)

117.986           AMA – My Medications APP

As a means of promoting the core values, vision and mission of the American Medical Association, while also helping to “brand” the AMA in a more positive light among physicians and patients, the New York Delegation urged the AMA to allow a free download (rather than the 99 cent charge) of their “My Medications” App, (which allows patients to store, carry and share their critical medical information on their iPhone, iPad, and iPod Touch), to all interested patients who utilize the services of an AMA member physician. (HOD 2012-207)  (AMA House Action:  Not Adopted) 

117.987           Internet Ranking/Rating of Physicians

The Medical Society of the State of New York will:

(1) work with appropriate entities to encourage the adoption of guidelines and standards consistent with AMA policy governing the public release and accurate use of physician data;

(2) continue pursuing initiatives to identify and offer tools to physicians that allow them to manage their online profile and presence;

(3) seek legislation that supports the creation of laws to better protect physicians from cyber-libel, cyber-slander, cyber-bullying and the dissemination of Internet misinformation and provides for civil remedies and criminal sanctions for the violation of such laws; and

(4) work to secure legislation that would require that the Web sites purporting to offer evaluations of physicians state prominently on their Web sites whether or not they are officially endorsed, approved or sanctioned by any medical regulatory agency or authority or organized medical association including a state medical licensing agency, state Department of Health or Medical Board, and whether or not they are a for-profit independent business and have or have not substantiated the authenticity of individuals completing their surveys.  (HOD 2012-257)

117.988        Role of Organized Medicine in Cyberspace Evaluations of Physicians:

MSSNY will work with legislators to secure legislation that would require that (1) the Websites purporting to offer evaluations of physicians state prominently on their Websites that they are not officially endorsed, approved or sanctioned by any medical regulatory agency or authority or organized medical association including a state medical licensing agency, state Department of Health or Medical Board but that they are a for-profit independent business and have not substantiated the authenticity of individuals completing their surveys; and (2) organized medicine have an input into the parameters used in the ratings of physicians on these Websites. Also, MSSNY is to bring this resolution to the 2010 American Medical Association House of Delegates Meeting.  (Council 1/28/10)

117.989           Anonymous Cyberspace Evaluations of Physicians:

MSSNY will:

-work with legislators to secure legislation to require that all online sites purporting to evaluate licensed physicians have systems in place to substantiate the authenticity of the persons completing their online surveys to be sure that the persons completing the evaluations are real bonafide patients and to require that there are controls in place to track and limit the number of responses;

-work with legislators to secure legislation that would make it a crime for a company or an individual that does business or resides in New York State to initiate, facilitate or contribute to on-line slander, libel and misrepresentation of identity or cyberbullying through the internet;

-work with legislators to secure legislation that would require a company or an individual that does business or resides in New York State that maintains a Website which purports to offer evaluations of physicians to register with the Attorney General of the State of New York and to be the subject of routine review for the purpose of determining whether said Website facilitates on-line slander, libel and misrepresentation of identify or cyberbullying;

-work with legislators to secure legislation that would make it a crime for a company or an individual that does business or resides in New York State to violate Internet user agreements.

In addition, MSSNY to bring a resolution on this subject to the American Medical Association.  (Council 9/17/09)

117.990           AMA Masterfile and AMA Physician Profile:

MSSNY will bring resolutions to the American Medical Association’s 2009 Annual House of Delegates Meeting requesting that:

-the American Medical Association (AMA) ensure that the AMA Physician Profile and AMA Masterfile include the complete name of the training program [i.e. “Program Name” as listed on the Accreditation Council for Graduate Medical Education (ACGME) website)];

-the AMA ensure that the AMA Physician Profile and AMA Masterfile stop deleting from Physician Profiles and the Masterfile the name of the medical school or training program that is already listed and verified in the Physician Profile as it corresponds to the name of the institution at the time of the Physician’s graduation;

-if the AMA Physician Profile and AMA Masterfile includes the new updated name of a medical school or training program, this information be in addition to but not in place of the name of the medical school or training program at the time of the physician’s graduation; and

-when the American Medical Association Physician Profile does its routine standard primary source verification confirming residency graduation, it states on the Profile “Completed Training” for the program from which a resident was graduated.  (HOD 2009-216)

117.991           Waivers – Mutual Privacy Agreements:

MSSNY will examine the use of “mutual privacy agreements” which are utilized by some physicians as a mechanism to prevent patients from posting unfavorable comments on blogs, and recently developed rating websites, as well as other such devices that pre-condition the provision of medical services upon the waiver of individual patient rights.  (HOD 2009-212)

117.992           Update nydoctorprofile.com:

 MSSNY will:

-work with the New York State Department of Health to ensure that the New York State Physician Profile includes the complete name of the training program [i.e. “Program Name” as listed on the Accreditation Council for Graduate Medical Education (ACGME) Website];

-work with the New York State Department of Health to ensure that the New York State Physician Profile stop deleting from the database the name of the medical school or training program that is already listed and verified in the Physician Profile as it corresponds to the name of the institution at the time of the physician’s graduation;

-work with the New York State Department of Health so that the New York State Physician Profile stops automatically overriding correct, accurate information contained in a physician’s profile with inaccurate or incomplete information contained in the AMA Masterfile and AMA Physician Profile;

-pursue efforts to assure that data on public physician profiles contain only correct and appropriate data and that a physician be notified of any changes made by the profiler to allow corrections.  (HOD 2009-156)

117.993           Information Technology and Stimulus Money:

MSSNY will (1) caution health care policy makers that the Health Care Information Technology stimulus money, as outlined in the American Reinvestment and Recovering Act, will cause a sudden rise in the demand for health care IT products and services which may result in inflated prices for physicians; (2) advise physicians and health care policy makers that the ongoing maintenance of health care IT can be costly, and that this ongoing expense will fall to physicians long after the stimulus money is exhausted; and (3) introduce a similar resolution at the upcoming American Medical Association A 2009 Annual Meeting.  (HOD 2009-93)

117.994        Medical Smart Cards:

MSSNY will urge the American Medical Association to study and develop a “white paper” on the issue of medical smart cards and aligned technology, including the role of organized medicine in smart card development, the emergence of regional health information organizations (RHIOs), the opportunity for State and Specialty Societies to obtain grants to educate and inform members of opportunities in this and similar emerging technology and to enumerate the implications which these technologies have for physicians, patients and healthcare, in general.  (HOD 2009-92; Reaffirmed HOD 2014)

117.995           Fully Functional Universal Health Information Network:

MSSNY will continue working collaboratively with all appropriately recognized entities on the state and federal levels and other healthcare stakeholders to ensure that the standards developed to make health information technology operational in communities across New York State will, in an affordable and user friendly manner, improve efficiency and accuracy in the delivery of healthcare.  (HOD 2009-91; Reaffirmed HOD 10-100)

117.996         EHR Interfaces

MSSNY will encourage the State of New York to (1) require electronic medical records sold in the state of New York to include, at no extra charge, interfaces that communicate with state-wide databases and local Region Health Information Organizations (RHIOs); and (2) set clear standards for electronic interfaces.  (HOD 2009-90)

117.997           Medical Smart Cards:

MSSNY will:

  1. educate its members through News of New York, the MSSNY website and other appropriate means of communication, regarding the benefits, technology and availability of medical smart cards, and keep members informed of developments and opportunities in this emerging technology.
  1. communicate with health care organizations and health insurance plans throughout New York State to urge the development and use of medical smart cards for the purposes of:
    1. making patients’ information readily available;
    2. simplifying the task of eligibility verification in physician offices, and
    3. enhancing and ensuring HIPAA compliance with conversion of paper-based health care information to electronic systems that guarantee the privacy and security of patient information gathered as part of providing health care.
  1. work with health care insurers and agencies to ensure that physicians do not incur any added expenses to incorporate the use of a health insurer’s / agency’s generated medical smart card into their practice. In addition MSSNY urge those entities, including vendors, which currently charge physicians a fee for smart card readers to provide these free or at a steep discount for MSSNY members.
  1. develop a collaborative working relationship with the HANYS’ newly created Office of Health Information Technology Transformation, which is studying the development of sustainable health information exchanges on community, regional, and state levels (Regional Health information Organizations or RHIOs). In addition, MSSNY will strive to become an active participant in the GNYHA newly created New York Clinical Information Exchange (NYCLIX) whose goal is to “increase patient safety and the efficiency of care by creating a virtual network for sharing of patient data among health care entities for the purpose of treatment.” NYCLIX is now embarking on the planning phase in order to create implementation of patient data sharing. Both of these initiatives (HANYS and GNYHA) are unique opportunities for MSSNY to provide physician input and expertise at the early stages of these projects.
  1. prepare a resolution to be forwarded to the AMA House of Delegates to study and develop a “white paper” on the issue of medical smart cards, including the role of organized medicine and specific implications for physicians, patients and healthcare, in general. (Council 1/25/09)

117.998           Information Technology:

MSSNY will encourage insurance companies to develop economic incentives, including increased reimbursement rates, for physicians and hospitals that use information technology in the care of their patients.  (HOD 2006-92; Reaffirmed HOD 2016)

117.999           Putting Economics in Health Information Technology:

MSSNY will continue to work jointly, with the American Medical Association and other organizations, to develop standards and protocols towards affordable and user friendly health information and payment systems.  (HOD 2006-81; Reaffirmed HOD 2016)

120.000      HEALTH INSURANCE COVERAGE: (See also Abortion and Reproductive Rights, 5.000; Alcohol and Alcoholism, 20.000; Reimbursement, 265.000)  

120.926           Private Insurers and Managed Care Organizations Pre–Authorization/Pre–Certification Protocols

The Medical Society of the State of New York (MSSNY) will seek legislation or regulation applying to all insurers which will:

Require insurance companies to provide clear instructions in a timely manner about the             procedure for obtaining a prior authorization;

Require that for each plan or product, the insurer post on its website a complete list of services requiring pre–certification/pre–authorization;

Require that after a physician has telephoned a customer service representative (CSR) to determine whether a service requires pre–certification/pre–authorization, the insurer will send a written confirmation of the CSR’s verbal statement by fax or e-mail to the physician;

Prohibit the insurer from denying a claim solely for lack of an electronic pre–authorization/pre–certification request, if (a) the CSR has stated verbally that the service does not require pre–authorization/pre–certification but that statement was inaccurate, and (b) the physician, relying on the CSR’s verbal statement, failed to submit an electronic pre–authorization/pre–certification request; and

Ensure that when pre-authorization is not required, a physician can request from the insurance company a written predetermination about whether a particular procedure will be covered for a particular patient, and that predetermination shall be binding. (HOD 2016-260 & 261) 

120.927           Deleting State or Federally-Mandated Coverage

The Medical Society of the State of New York will seek federal regulation or legislation that prohibits self-insured health insurance companies from deleting coverage mandated by government. (HOD 2016-259)

 120.928           Transfer of Insureds to Other Carriers without Proper Notification

The Medical Society of the State of New York (MSSNY) will work with the appropriate state agencies to enact regulation banning the transfer of insureds or contract term changes without appropriate and easy to understand written notice of at least 90 days prior to the planned transfer. (HOD 2016-258) 

120.929           Improving Medical Insurance Customer Service

The Medical Society of the State of New York (MSSNY) will seek regulation or legislation which ensures that all coverage information be made available to health insurance customer service agents to review with patients during phone conversations.

MSSNY will seek regulation or legislation which ensures that all insureds be furnished with copies of their coverage directly through the insurer upon request and that a copy of an insured’s policy be made available through the online login at all times. (HOD 2016-255) 

120.930           Centralized Insurance Registry

The Medical Society of the State of New York (MSSNY) working with the New York State Department of Health — Office of Health Insurance Programs will seek establishment of a centralized system of insurance eligibility accessible to all providers. (HOD 2016-254) 

120.931           NYS Private Payer Medical Necessity Guidelines

MSSNY will support legislation and/or regulation which prohibit insurance companies from using proprietary guidelines to deny pre-authorization and/or payment. (HOD 2016-251)

120.932           Insurance Simplification of Explanation of Benefits (EOBs)

The Medical Society of the State of New York will seek regulation or legislation that would require all claims from a health care provider relating to a single encounter be reported together on the same EOB, rather than across multiple EOBs in order to make the claims process more simple and transparent. (HOD 2016-51) 

120.933           Limitation on Outpatient Therapy Copayments

As a result of increased physical therapy co-pays, which often cause patients to delay medically necessary treatment, the Medical Society of the State of New York should seek legislation or regulation which would limit a patient’s out-of-pocket co-pay for  a prescribed course of physical therapy treatment, thereby making it financially viable for a patient to obtain these needed services.  (HOD 2015-266)

120.934           Payments by Medicare Supplemental Policies

The Medical Society of the State of New York will take appropriate action to educate MSSNY members through the E-news and the News of New York about their patients Medigap Plans so that physicians can, in turn, educate their  patients’ about the benefits associated with the supplemental policies they have purchased.  (HOD 2015-265) 

120.935           Non-Experimental Status Determined by Centers for Medicare and Medicaid Services

The Medical Society of the State of New York will seek by regulation and/or legislation New York State policy/law requiring that any medical service deemed non experimental by the Centers for Medicare and Medicaid Services for government programs also be deemed non-experimental by private payors. (HOD 2015-254)

120.936           Requiring Insurance Companies to Cover ADD/ADHD Medications

For children who have already previously been successfully stabilized on a specific ADD/ADHD medication, the Medical Society of the State of New York (MSSNY) will pursue legislation and/or regulation that requires an insurer to continue to cover, at lowest tier cost, or patient cost-share, that same medication for children, and do so without obstructions, such as prior authorization or required trials of alternate medications, if and when that insurer changes their formulary policies.

For children who have already previously been successfully stabilized on a specific ADD/ADHD medication, but change insurer, or have a change in policy program within that same insurer, MSSNY will pursue legislation and/or regulation that requires an insurer to continue to cover, at lowest tier cost, or patient cost-share, that same medication for children, and do so without obstructions, such as prior authorization or required trials of alternate medications, if and when that insurer changes their formulary policies. (HOD 2015-252) 

120.937           HCV Testing and Treatment

The Medical Society of the State of New York will send a letter to the New York State Division of Financial Services seeking a requirement that commercial insurers provide coverage for the HCV test.  MSSNY will seek, by legislation if needed, to ensure that commercial insurance coverage for the HCV test and access to HCV treatment is required. (HOD 2015-160) 

120.938           Out of Network Coverage Denials for Physician Prescriptions and Ordered Services

MSSNY will pursue regulation or legislation to prohibit any insurer from writing individual or group policies which deny or unreasonably delay coverage of medically necessary prescription drugs or services based on network distinctions of the licensed health care provider ordering the drug or service.  (HOD 2015-69) 

120.939           Physician-Directed Medication Access

The Medical Society of the State of New York will continue to advocate for:

Legislation which will ensure that the physician’s judgment regarding the necessity of a particular medication for their patient prevails over an insurer’s judgment, including for all patients insured through Medicare and Medicaid;

Legislation or regulation that would prohibit an insurer from denying care for needed treatment or medications unless it is reviewed by a physician of the same specialty as the treating physician; and 

Legislation, regulation, or other appropriate means to assure that health plans consult with appropriate specialty physicians in the creation of formularies and policy regarding drug-tiers.  (HOD 2015-53; Reaffirmed HOD 2016-67) 

120.940           Patient Educational Tools on Insurer Administrative Policies

The Medical Society of the State of New York will develop a series of educational tools for members to give to their patients that will inform patients about policy and administrative problems caused by insurance plans making it more difficult for physicians to provide needed, quality health care and these Patient Educational Tools on insurer processes will state how insurers have interfered with physicians or otherwise constrain physicians from delivering what they believe to be the best quality care. (Amended and adopted by Council, 11/20/2014.  From HOD 2014-257) 

120.941           Affordable Care

The Medical Society of the State of New York will advocate for regulation and legislation which provides that insurers give reasonable credit for out of network expenses based on Fair Health toward a participant’s annual deductibles and out of pocket maximums.  MSSNY will submit a resolution to the annual meeting of the American Medical Association seeking federal regulation and legislation to provide that insurers give reasonable credit for out of network expenses toward a participant’s annual deductibles and out of pocket maximums. (HOD 2014-253)

120.942           Thoroughly Informing Patients and Physicians About Out-Of-Network Benefit Reduction
                           and Cancellation

The Medical Society of the State of New York (MSSNY) will take all possible appropriate steps, utilizing all possible methods including public relations, to fully and thoroughly educate patients and the public about the emerging realities of out-of-network benefits, and the Medical Society of the State of New York will make every conceivable effort to communicate more fully and completely with its membership regarding what will transpire regarding out-of-network care since physicians too are under-informed. (HOD 2014-254)

120.943           Physicians and Health Care Institutions as Providers of Health Insurance

In the case where a provider or health care institution provides such insurance it should be held to the highest standards and oversight to prevent conflicts of interest that impair quality care; and any institution in the business of health care insurance have on its governance board and/or advisory boards, community providers as long as they are not employees of the institution providing such insurance. (HOD 2014-112)

120.944           Changes in Pre-certification for Medications to Reduce Delays

The Medical Society of the State of New York will continue to advocate to reduce the circumstances when pre-authorization for needed patient medications are required, including eliminating the requirement for annual re-authorization once a prior authorization for a prescription medication has been approved.  The Medical Society of the State of New York will advocate to ensure that health plan pre-authorizations for prescriptions be completed within 24 hours. (HOD 2014-58; Reaffirmed HOD 2015-53) 

120.945           Access to Timely Care

The Medical Society of the State of New York will advocate for legislation or regulation to assure the right of a patient to have insurance coverage which permits them to be treated by an out of network physician of the patient’s choice if the plan network is inadequate to enable a patient to be treated by a needed specialist within 14 days of the patient’s request, with payment based upon usual and customary rates. (HOD 2014-60)

120.946:          Cost-saving Public Coverage for Renal Transplant Patients

MSSNY will ask the AMA to support private and public mechanisms that would extend insurance coverage for the full spectrum of renal transplant care for the life of the transplanted organ; and ask the AMA to offer technical assistance to individual state and specialty societies when those societies lobby state or federal legislative or executive bodies to implement evidence-based cost-saving policies within public health insurance programs. (HOD 2013-266)

120.947:          Collapse Individual and Small Group Insurance Markets

MSSNY will seek legislation and/or regulation to eliminate the (newly obsolete) health insurance premium pricing differential that exists between the individual and small group pools. (HOD 2013-264)

120.948:          Third Party Payer Coverage of Follow Up Exams for Patients with Dense Breast Tissue

MSSNY will seek legislation to require insurance companies and other third party payers to pay for follow up exams for women who receive a report of dense breast tissue. (HOD 2013-154)

120.949           Health Insurance Policies for Small Groups

In view of health insurance companies moving to eliminate many or all of the health insurance plans being offered to small groups (2-50 employees), while also dramatically reducing the financial incentives for brokers to market their plans, and continuing to raise premiums on small businesses at rates that are making such insurance unaffordable, that the Medical Society of the State of New York urge the Department of Financial Services to require all health insurance companies operating in the State of New York to offer a wide array of health insurance sufficient number of affordable products to small groups, both within the health insurance exchange and outside of the exchange. (HOD 2012-55; referred, modified & adopted by Council 11/29/2012)

120.950           Regulation and Transparency of Imaging Benefit Managers’ Contracts

The Medical Society of State of New York will seek legislation that any health plan, or its business partner, conducting prior authorization for non-urgent and non-emergent services or procedures 1) respond to these requests within two business days; 2) utilize recognized standards of care and comply with any published specialty society-approved practice guidelines; 3) ensure that their authorization criteria conform with their health plan’s published policy available to the public for any and all service needing prior authorization; and 4) in the event of denied authorization, an expedited peer-to-peer appeal be conducted within the day (24-hour period) so that no potentially harmful delays befall the patient and that compliance with these rules be monitored by the NYS Department of Health. (HOD 2012-253) 

120.951           Clear Statement of Coverage on Health Insurance ID Cards

The Medical Society of the State of New York (MSSNY) will work with insurers to develop standardized information to be required on all health insurance ID cards which clearly states services, co-pays, and other vital coverage data purchased by the insured. (HOD 2012-255; Reaffirmed HOD 2016-256)

 

120.952           Insurance Companies Dis-enrollment of Participating Physicians

The Medical Society of the State of New York will seek legislation that would expand physician protections similar to those enunciated in Public Health Law § 4406-d for non-renewal of a network contract for both managed care plans and HMOs in order to enable physicians to have the right to appeal a plan’s non-renewal decision and have a hearing, if needed.

The Medical Society will urge the Department of Financial Services to require that all health insurance companies doing business in the State of New York, provide clear and concise justification with appropriate documentation, which substantiates a decision to terminate or non-renew a physician’s participation status.  When a physician receives a notification that his/her participation agreement is being terminated or not renewed, an appropriate appeals mechanism be provided which allows adequate time for the physician to seek appropriate counsel (if necessary) and to assemble any necessary and supporting documentation which may be needed to assist in the appeal. (HOD 2012-259)

120.953           Transparency in Insurance Contracts:

MSSNY will seek legislation and/or regulation that would enforce health insurance plans to clearly and transparently declare what exactly is covered and not covered in each of their plans in a plain, simple and concise summary, with carefully documented exclusions to coverage, in a standardized format to be approved by the New York State Superintendent of Insurance.  Also such legislation and/or regulation should state that once these limitations of coverage are outlined they cannot be changed without first notifying the insured of these changes in a timely manner, sufficient enough to allow an insured the ability to change policies without disruption to healthcare coverage.  (HOD 2010-260)

120.954           Child Health Plus Program Funding:

MSSNY will continue to work with New York’s Congressional Delegation and the AMA to assure that federal funding for care provided to beneficiaries of the Child Health Plus and Medicaid programs in New York is not diminished in the future.  (HOD 2010-91)

120.955           Truth in Out-of-Network Healthcare Benefits Act:

MSSNY will seek legislation and/or regulation to require insurance companies to provide to potential purchasers the true expected out-of-pocket costs if patients to out of network.  Also, MSSNY to endorse the AMA draft legislation, Truth in Out-of-Network Healthcare Benefits Act, and seek adoption of similar legislation in the State of New York.  (HOD 2010-58)

120.956           Out-of-Network Care by Health Plan Providers:

MSSNY will petition health plans as well as the New York State Insurance Department to allow the health plan’s physician to charge a subscriber as an out-of-network provider when the subscriber is not an enrolled member of the physician’s specifically contracted health plan product. (HOD 2009-262)

120.957           Outsourcing of Claims:

MSSNY will take all appropriate steps including, if necessary, the passage of legislation to assure that health insurance companies which subcontract with third party vendor(s) located in a foreign country for claims processing, utilization review or for any other service adhere to all appropriate federal and state legal requirements for the prompt adjudication of claims for payment, utilization review and patient information privacy.  (HOD 2009-105)

120.958           Eligibility for Enrollment in Family Health Plus:

MSSNY will seek a change to the current eligibility requirements for enrollment in Family Health Plus to allow for small businesses, including physicians’ offices, with less than 10 full time employees to be able to offer Family Health Plus as an additional insurance option.  (HOD 2009-102)

120.959           Revision of the Federal Tort Claims Act:

MSSNY will endorse the proposal that all patients whose care is funded in all or in part by federal funds, and/or whose care is delivered in facilities funded in all or in part by federal funds, such as those patients covered by Medicare, Medicaid, Railroad retirement benefits, SCHIP, insurance purchased with pre-tax dollars, treated in not-for-profit facilities, etc., be brought under the jurisdiction of the Federal Tort Claims Act.  Also, the MSSNY delegation to the American Medical Association is requested to take this issue to the 2009 AMA House of Delegates for action on the federal level.  (HOD 2009-75)

120.960           Assuring Seamless Coverage for Patients Changed from HMO  Products into PPO Products:

MSSNY will seek federal and state legislation to eliminate the 12-month awaiting period for health insurance coverage for patients with pre-existing medical conditions and request that the American Medical Association’s 2009 House of Delegates consider this action as well.  (HOD 2009-68)

120.961           Impediments to Obtaining Pre-authorizations for Medically Indicated Diagnostic Tests:

MSSNY will take appropriate steps including, if necessary, seeking the enactment of legislation and regulation, to eliminate unnecessary impediments imposed by health insurance companies to obtaining pre-authorization, including reducing the need and time for obtaining pre-authorization.  (Council 3/3/08; Reaffirmed HOD 2014-58)

120.962           United States Health Care and Gratuitous Privatization:

MSSNY supports those health care policies that favor insurance products to achieve the health care goals of quality, cost containment and interoperability, only when the evidence in support of the superiority of such insurance products is composed of unbiased, scientifically rigorous and medically sound studies.  (HOD 2008-93)

120.963           Retail Clinics:

MSSNY will pursue legislation, regulation, or other appropriate means to (a) assure that a retail clinic that receives insurer reimbursement be required to comply with existing standards for the operation of medical practices; and (b) prohibit health plans from incentivizing the utilization of health care in retail stores through techniques including but not limited to the charging of less expensive co-pays. (HOD 2008-68)

120.964           Universal Bill:

MSSNY will seek legislation or other appropriate means to assure that all durable medical equipment (DME) vendors have a universal bill that is consumer-friendly and clearly states what was paid by the health plan, secondary insurer and what is owed by the patient and that these bills are received in a timely fashion. (HOD 2008-61)

120.965           Medically Necessary Procedures and Pre-certification and Pre-authorization Protocols:

MSSNY will:

  1. Seek the enactment of legislation, regulation or other appropriate means to eliminate the need to obtain pre-authorization for certain procedures and tests that are clearly indicated, including for urgent and emergency care, based upon a patient’s particular health condition as defined by relevant physician specialty society guidelines;
  1. Take appropriate steps to assure that health plans obtain meaningful clinical input from New York physicians representative of all specialties, through practicing physician liaison committees, in determining which services should require pre-authorization or pre-certification;
  1. Take appropriate steps to assure that health plans promptly respond to required pre-authorization requests for tests within 24 hours, including the imposition of meaningful penalties on health plans, and requiring payment for the requested services when such authorization is not received in a timely manner;
  1. Advocate for a statutory definition of “medical necessity” which gives appropriate discretion to a physician requesting the health care service or treatment for the patient, provided the care is consistent with generally accepted standards of medical practice, and clinically appropriate to the patient’s condition. (HOD 2008-50; Reaffirmed HOD 2016-262)

120.966           Coverage by Carriers for Annual Physical Examination in Healthy NY Program:

MSSNY will encourage the Healthy NY Program to negotiate a benefit package that allows for an annual health maintenance visit.  (HOD 2008-264) 

120.967           Hearing Aids:

MSSNY will work with the American Medical Association to encourage all insurers, including Medicare, to provide coverage for hearing aids for individuals determined by professionals to be hearing impaired.  (HOD 2008-263)

120.968           Waiver of Primary Care Referral Requirements for Skilled Nursing Facilities and Sub-Acute Rehabilitation Facilities:

MSSNY will pursue legislation and/or regulation to simplify and make transparent the health coverage of Skilled Nursing Facilities/Sub-Acute Rehabilitation Facility residents, by waiving the primary care referral requirement so that patients receive timely and appropriate treatment and appropriate reimbursement is provided for these services.  (HOD 2008-262)

120.969           Removing Barriers to Care for Transgender Patients:

MSSNY supports the resolution being presented at the American Medical Association’s A’08 Meeting by the AMA-Medical Student Section and AMA-Resident and Fellow Section which asks that the AMA (1) support public and private health insurance coverage for treatment of gender identity disorder, and (2) oppose categorical exclusions of coverage for treatment of gender identity disorder when prescribed by a physician.  (HOD 2008-171)

120.970           Health Coverage Coalition for the Uninsured:

MSSNY approves the conclusions of the Health Coverage Coalition for the Uninsured and express its concern that additional issues of significance should be also addressed by HCCU including but not limited to the burdensome cost associated with the administration of current health care coverage, the need for redress of the medical liability problem, and the need to obtain leverage in the health care market through collective negotiation.  (Council 3/5/07; Reaffirmed by Council 11/29/2012 in lieu of 2012-260)

120.971           Medical Outsourcing:

MSSNY will request legislation to prevent insurance companies from incentivizing subscribers in this state to have to go overseas for medical treatment that could be provided locally and, through the American Medical Association, request federal legislation to prevent insurance companies from incentivizing subscribers to go overseas for medical treatment that could be provided locally.  (HOD 2007-263)

120.972           Association Health Insurance:

MSSNY will seek legislation or regulation to enable insurers to provide association-specific health insurance alternatives for 501(c)(6) not-for-profit associations in the State of New York.  (HOD 2007-211)

120.973           Health Promotion Visits:

MSSNY should seek legislation and/or regulation exempting the cost of an annual physician clinical preventive services visit, as defined in current MSSNY policy 120.983, from inclusion as deductible expenses. (HOD 2007-156)

120.974           Access to Health Insurance for Domestic Partners:  (Sunset HOD 2016)

120.975           Home Visits

MSSNY work to assure appropriate reimbursement for rendering care to homebound individuals.  (HOD 2004-64; Reaffirmed HOD 2014)

120.976           Geriatric Care

MSSNY will work to assure appropriate reimbursement by all payors for care provided to the elderly.  (HOD 2004-62; Reaffirmed HOD 2014)

120.977           Patients’ Out of Pocket Financial Responsibility for Emergency Room Services Provided:                            SUNSET HOD 2014

120.978           Public Access to Health Insurance Policy Options Available to Government Employees:
S
UNSET HOD 2013

120.979           Patient Responsibility for Notification of Change in Insurance Coverage:  SUNSET HOD 2013

120.980           Clean Claim:  Sunset HOD 2011

120.981           Standardized Referral Form:  SUNSET HOD 2014

120.982           “Bare Bones” Health Insurance Policies:  SUNSET HOD 2014

120.983           Payment for Clinical Preventive Services

MSSNY will seek the introduction of state legislation, as well as federal legislation through the AMA, requiring all insurance companies (Indemnity and ERISA Health Plans) to pay for at least one visit a year for clinical prevention services, and that no other diagnosis be required for payment to the physician.  (HOD 1999-264; Reaffirmed HOD 2007-156)

120.984           Parity in Reimbursement for Mental Health Services  SUNSET HOD 2014

120.985           Call for the Closure of Wellcare of New York SUNSET HOD 2014

120.986           Non-Assignability Clauses in Health Insurance Contracts:

MSSNY supports the patients’ right to assign their health insurance benefits to their physician, and shall seek legislation that would prohibit non-assignability of benefits clauses from all health insurance contracts.  (HOD 1999-61; Reaffirmed HOD 01-66; HOD 2008-56; Reaffirmed HOD 2009-63)

120.987           Multiple Product Lines:

MSSNY through the American Medical Association will seek Federal Legislative action to challenge health insurers who mandate the commitment of physicians to all (or multiple) product lines under a single contractual agreement as a condition for their participation with such organizations.(Council 12/18/97; Reaffirmed HOD 2014)

120.988           MSSNY Position on Child Health Plus Program (CHPlus)SUNSET HOD 2014

120.989           Routine and Refractive Eye Examination:

It is MSSNY’s position that third-party payors make it abundantly clear to patients that eyeglass riders, routine eye examinations, vision care services, vision benefits, vision aid benefits, vision care benefits, eyeglass benefits and any such benefits, as desirable as they may be, do not substitute for a full medical eye examination on a regular basis by a qualified ophthalmologist, and that when eyeglass benefits are provided, that such benefits provide coverage for a refractive examination and prescription of eyeglasses by an ophthalmologist or optometrist of the patient’s choice.  MSSNY will coordinate efforts with medical specialty societies to introduce legislation requiring third-party payors to use uniform and precise language to describe benefits provided in eyeglass benefits and riders, and make it clear to patients that such examinations do not substitute for a full medical eye examination on a regular basis.  (HOD 1998-78; Reaffirmed HOD 2014)

120.990           Physician Notification of Insurance Payments Made Directly to Patients

MSSNY will seek legal or regulatory action to require that insurance carriers be mandated to notify physicians of the amount and date of insurance claim payments made directly to their subscribers, regardless of the physician’s participation status in the plan.  (HOD 1998-52; Reaffirmed HOD 2014)

120.991           Certain Types Of Well Examinations To Be Covered By All InsurersSUNSET HOD 2014

120.992           Insurance Companies To Cover Screening Mammography:

MSSNY will seek requiring all health insurance products to cover mammography whenever the patient’s physician deems it medically appropriate.  (HOD 1997-255; Modified and reaffirmed HOD 2014)

120.993           Smoking Cessation Reimbursement:  SUNSET HOD 2014

120.994           Insurers To Cover Hepatitis B Immunization  SUNSET HOD 2014

120.995           Parity of Coverage for Mental Illness, Alcoholism and Substance Abuse  in Medical
                          Benefits Programs endorsed by MSSNY
:  SUNSET HOD 2014

120.996           Standardized Insurance Claim Forms:  SUNSET HOD 2014

120.997           Truth in Health Insurance:

MSSNY takes the position that all health insurance literature and contracts should be mandated to use a standardized form, written in laymen’s terms (easy to understand language), wherein excluded diseases, diagnoses, and medical procedures are appropriately identified in policies of contract holders.  As a means of allowing subscribers to make informed decisions concerning their health insurance choices, the Medical Society of the State of New York is urging the New York State Insurance Department to support legislation which would amend the insurance law in relation to the adoption of current procedural terminology for use by health insurers, as well as requiring insurers to release information on the mode of payment in addition to the actual reimbursement for services rendered to enrolled subscribers.  (HOD 1992-37; Reaffirm HOD 2014)

120.998           Reimbursement When Patients Refuse to Sign Health Insurance Forms:  MSSNY is urgently requesting the New York State Department of Insurance to draft measures which would ensure that health insurance companies be obliged to reimburse physicians for documented medical services performed in accordance with the patient’s insurance plan whether or not the patient agrees to sign the insurance forms. (Council 7/23/92; Reaffirmed HOD 2014)

120.999           Health Insurer Abuses:

MSSNY has urged the Superintendent of Insurance to enhance the means by which consumer and physician complaints regarding health insurance programs are addressed in a timely, informed and effective manner, through:  (1)  Development and identification of clearly defined complaint and review procedures;  (2)  Imposition of penalties designed to deal with insurance carrier abuses;  (3)  Provisions of 1-800 number enabling consumer and physician access to appropriate personnel associated with established appeals and grievance processes.

MSSNY is vigorously pursuing legislation or regulation to limit health insurance abuses which would include specific requirements with respect to the responsibility of the Superintendent of Insurance to more adequately monitor the activities of health insurers in the State.  (HOD 1991-34; Reaffirmed HOD 2014; Reaffirmed HOD 2016-262)

125.000           HEALTH SCREENING PROGRAMS:

125.992           Promoting Population Health through Primary Care

The Medical Society of the State of New York supports workforce wellness programs and encourages wellness programs that connect beneficiaries to their primary care physician and include the appropriate screening services and referral for primary, secondary and tertiary prevention.

MSSNY encourages physicians to recommend to every patient that they have a current wellness visit.  (HOD 2016-167)

125.993        Physician Health Programs and Membership Recruitment

Together with county medical societies, district branches and the Committee for Physician Health, the Medical Society of the State of New York will develop a series of programs, which may include CME credit, to assist physicians in early identification and management of stress.  The programs will concentrate on the physical, emotional and psychological aspects of responding to and handling stress in physicians’ professional and personal lives, and when to seek professional assistance for stress-related difficulties.  (HOD 2015-200) 

125.994           Use of CT Scans for Early Detection of Lung Cancer

The Medical Society of the State of New York supports screening for lung cancer with low dose computed tomography for patients who meet current nationally recognized guidelines. (HOD 2014-157)

125.995           Breast MRI for High Risk Women

The Medical Society of the State of new York supports the American Cancer Society and the American College of Radiology recommendation that screening breast MRI is indicated in patients who are at high risk for breast cancer in addition to mammography. (Council 1/12/2012)

125.996           Screening Programs and Interventions Most Beneficial in Improving the Overall Health of the Public:

MSSNY has found that the following screening programs and interventions are most beneficial in improving the overall health of the public:

Essential Behavioral Changes

1)   Smoking Cessation and Counseling –  Tobacco cessation counseling on a regular basis is recommended for all persons who use tobacco products.  Pregnant women and parents with children living at home also should be counseled on the potentially harmful effects of smoking on fetal and child health. (US Preventive Services Task Force).

2)   Healthy Diet Counseling and Nutritional Intervention  –  Counseling adults and children over age 2 to limit dietary intake of fat (especially saturated fat) and cholesterol, maintain caloric balance in their diet, and emphasize foods containing fiber (i.e., fruits, vegetables, grain products) is recommended.  A variety of groups have recommended nutritional counseling or dietary advice for patients at average risk for chronic disease, including the American College of Preventive Medicine (ACPM), American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), and the American College of Obstetricians and Gynecologists (ACOG).  Recommendations on nutritional counseling for patients at risk (e.g., those who have hypertension or hyperlipidemia) have been issued by the American Dietetic Association (ADA) and two panels sponsored by the National Institutes of Health (NIH) National Heart, Lung, and Blood Institute.  The ADA recommends that primary care providers screen for nutrition-related illnesses, prescribe diets, provide preliminary counseling on specific nutritional needs, follow up with patients, and refer patients to appropriate dietetic professionals when necessary. (http://www.ahrq.gov/clinic/3rduspstf/diet/dietrr2.htm – ref52)

3)  Exercise Promotion  –  Counseling patients to incorporate regular physical activity into their daily routines is recommended to prevent coronary heart disease, hypertension, obesity, and diabetes.  This recommendation is based on the proven benefits of regular physical activity (Department of Health and Human Services (Healthy People 2010) Centers for Disease Control and Prevention, National Center for Education in Maternal and Child Health (Bright Futures), American Academy of Family Physicians, American Academy of Pediatrics, The American Heart Association, and The American College of Obstetricians and Gynecologists). 

Essential Preventive Screening

1)  Hypertension Screening and Treatment  –  Screening for hypertension in adults in adults aged 18 and older.  (US Preventive Services Task Force).

2)   Diabetes Screening and Treatment  –  Screening for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg is recommended. (US Preventive Services Task Force).  The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for type 2 diabetes in asymptomatic adults with blood pressure of 135/80 mm Hg or lower.

3)  Primary Prevention of CVD in Adult    Frequency of Screening  In general, a comprehensive assessment of risk factors should be performed at least every 5 years starting at 18 years of age, and a global risk score should be calculated at least every 5 years starting at the age of 35 years for men and 45 years for women.  Those with increased cardiovascular risk, for example, those with diabetes, cigarette smokers, or those with obesity, should have their risk factors and cardiovascular risk assessed more frequently.  (J Am Coll Cardiol, 2009; 54:1364-1405, doi:10.1016/j.jacc.2009.08.005 © 2009 by the American College of Cardiology Foundation).

4)  Primary Prevention of Stroke  –  Guidelines include well-known prevention measures such as controlling high blood pressure, not smoking, avoiding exposure to secondhand smoke, being physically active and treating disorders that increase the risk of stroke such as atrial fibrillation (a type of irregular heartbeat), carotid artery disease and heart failure.  The guidelines suggest physicians consider using a risk assessment tool such as the Framingham Stroke Profile to assess patients’ risk.  (American Heart Association/American Stroke Association; US National Institute of Neurological Disorders and Stroke).

5)  Breast Cancer Screening Mammography and Appropriate Treatment  –  Women age 40 and older should have a screening mammogram every year and should continue to do so for as long as they are in good health.  Breast self exam (BSE) is an option for women starting in their 20s.  Women should be told about the benefits and limitations of BSE.  Women should report any breast changes to their health professional right away.  Women in their 20s and 30s should have a clinical breast exam (CBE) as part of a periodic (regular) health exam by a health professional, at least every 3 years. After age 40, women should have a breast exam by a health professional every year.  (Screening Guidelines for the Early Detection of Cancer in Average-risk Asymptomatic People—American Cancer Society).  Criteria for the use of breast MRI screening as an adjunct to mammography for high risk women include: having a BRCA 1 or 2 mutation; having a first-degree relative with a BRCA 1 or 2 mutation and are untested; having a lifetime risk of breast cancer of 20-25 percent or more as defined by models that are largely dependent on family history; received radiation treatment to the chest between ages 10-30 such as Hodgkin’s Disease; carry or have a first-degree relative who carries a genetic mutation in the TP53 or PTEN genes.  (Saslow D, Boetes C, Burk W, et. al.  American Cancer Society Guidelines for Breast Screening with MRI as an Adjunct to Mammography.  CA Cancer J Clin 2007:57:75-89).

6)  Colon Cancer Screening and Appropriate Treatment  –  Annual, starting at age 50 for all asymptomatic persons at average risk–Fecal occult blood test (FOBT) with at least 50% test sensitivity for cancer or fecal immunochemical test (FIT) with at least 50%test sensitivity for cancer or stool DNA test.  Flexible sigmoidoscopy every 5 years starting at 50 years of age or colonoscopy starting at age 50 every 10 years.  High risks patients should be screened based on their individual medical or family history.  (Screening Guidelines for the Early Detection of Cancer in Average-risk Asymptomatic People—American Cancer Society).

7)  Cervical Cancer Screening and Appropriate Treatment  –  Cervical cytology screening is recommended every two years for women aged 21-29 with either conventional or liquid based cytology.  Women aged 30 years of age and older who have had three consecutive negative cervical cytology screening test results and who have no history of CIN 2 or CIN 3, are not HIV infected, are not immunocompromised, and were not exposed to diethylstilbestrol in utero may extend the interval between cervical cytology examinations to every three years.  Co-testing using the combination of cytology plus HPV DNA testing is an appropriate screening test for women older than 30 years.  Any low-risk woman aged 30 years or older who receives negative test results on both cervical cytology screening and HPV DNA testing should be rescreened no sooner than three years subsequently.  American College of Obstetricians and Gynecologists Clinical Management Guidelines for Obstetrician-Gynecologists, Number 109, December 2009).

8)  Prostate Cancer Screening and Treatment in high risk individuals and populations (African-Americans and Men with a first degree affected relative)  –  For men, age 50+, digital rectal examination [(DRE and prostate-specific antigen test (PSA)].  Health care providers should discuss the potential benefits and limitations of prostate cancer early detection testing with men and offer the PSA blood test and the digital rectal examination annually, beginning at age 50, to men who are of average risk of prostate cancer, and who have a life expectancy of at least 10 years.  (Screening Guidelines for the Early Detection of Cancer in Average-risk Asymptomatic People—American Cancer Society).

9)  Immunizations  –  The best way to reduce vaccine preventable diseases is to have a highly immune population.  Appropriate vaccinations should be available for all adults including the following: Seasonal influenza, pneumococcal polysaccharide, Zoster (shingles), Hepatitis B and A, Tetanus, diphtheria, pertussis, polio (for adults who never received or completed the primary series of polio vaccine), varicella for adults who are without evidence of immunity, meningococcal, MMR (measles, mumps and rubella for persons born in 1957 or later or born outside the US), HPV for women through age 26 years of age.  (From the recommendations of the Advisory Committee on Immunization Practices).

Further, MSSNY recommends that physicians concentrate on these interventions for all of their patients and that New York State policy makers devote its limited public resources to these screening and treatment interventions on behalf of those adults unable to afford health care.  Also, for each intervention, physician and patient should discuss the positive and negative aspects.  (Council 3/8/10; Reaffirmed by Council 1/20/11 in lieu of 2010-163)

125.997           Barriers to Colorectal Cancer Screening:

With regard to Colorectal Screening, MSSNY is to:

– stress to the physician community the importance of counseling patients on the issue of colorectal cancer and the availability of a readily available screening test and procedure to detect this entity early in its course;

– take an active role through media, press, communication with senior groups and other community organizations to educate the public on the importance of routine colorectal screening tests and the importance of discussing with their Primary Care Physician any fears or concerns they may have, which are potential barriers to undergoing this procedure;

– support state financial mechanisms that allow uninsured patients to receive colorectal screening.  (HOD 2010-164)

125.998           Use of CT Scans for Early Detection of Lung Cancer:

MSSNY to place on its website the white paper, Use of CT Scans for Early Detection of Lung Cancer, drafted by its Heart, Lung and Cancer Committee.  (HOD 2007-164)

125.999           Test Results of Multiphasic Screening Programs:

It is the position of MSSNY that organizations, agencies or other entities that operate or sponsor multiphasic health screening programs should be urged to include in their promotional and explanatory materials on the availability of the program, a definitive statement that reports on the screening test results will be furnished to the individual participants only, and that each participant is responsible for obtaining any needed medical evaluation or follow-up should the results of the tests deviate from the normal range.  Those operating or sponsoring multiphasic health screening programs should also be urged to utilize report forms that state, in bold-face type, that the report does not constitute a medical diagnosis or evaluation and that the participant should consult a physician of his or her choice if the screening test results are not within the normal limits indicated on the report.  (Council 12/16/82; Reaffirmed HOD 2013)

130.000      HEALTH SYSTEM REFORM: (See also Education, 85.000; Health Care Delivery Systems, 110.000; Managed Care, 165.000; Reimbursement, 265.000)

130.932           Encourage Use of NYS Record Release Form

The Medical Society of the State of New York (MSSNY) recommends to physicians that their office staff utilize the New York State Authorization for Release of Health Information pursuant to HIPAA (OCA Office Form No. 960). (HOD 2014-250)

130.933           Workers’ Compensation and No-Fault Carriers to Use Diagnosis Codes Consistent with HIPAA Electronic Standards

The Medical Society of the State of New York (MSSNY) will seek legislation at the state level that requires all insurance carriers operating in New York State to utilize a consistent International Classification of Diseases (ICD) system. (HOD 2014-262)

130.934           MSSNY Single Payer Healthcare Survey

MSSNY, with input from the medical student section, design and conduct an objective poll by email of the collective opinion of MSSNY members and non-members ascertaining both their knowledge of the single payer health care system and their support or opposition of such a system in the State of New York. (HOD 2014-109) 

130.935           Long Term Care – The Impending Crisis

The Medical Society of the State of New York recognizes the crisis of long term health care financing and will look for innovative programs which would balance individual responsibility for long term health care costs and society’s role in making long term health care insurance available to all.  It is position of the Medical Society that people should be allowed to purchase long term care insurance with continued positive and no negative tax implications and those who exhaust private insurance benefits be automatically enrolled in the Medicaid program without a need to spend down their assets. 

The Medical Society of the State of New York work will work with the AMA to support a public option to cover the long term health insurance needs of all Americans through a Long Term Health Insurance Trust Fund financed with fees paid by all Americans during their lifetime.  (HOD 2014-115)

130.936           Affordable Care Act and NYS Medical Tort Reform

As part of its advocacy efforts to achieve comprehensive medical liability tort reform, the Medical Society of the State of New York should educate the public that patient access to necessary care is being threatened by the confluence of decreased payment from health insurers resulting from implementation of the Affordable Care Act and the exorbitant cost of medical liability insurance. (HOD 2014-51) 

130.937           Exclusion of Physicians from the New York State Health Benefit Exchanges

The Medical Society of the State of New York will continue to advocate to the Governor’s office, New York State Health Insurance Exchange officials, the New York State Legislature and New York’s Congressional delegation that all plans sold inside and outside of New York’s Health Insurance Exchange have robust physician networks that enable patients to have sufficient choice of treating physicians and enable patients to continue to be covered for care provided by physicians with whom there are long-standing treatment relationships.  The Medical Society of the State of New York will take efforts to prevent hospitals from directing their physician employees to not refer patients to private-practice physicians.  The Medical Society of the State of New York will continue its ongoing public relations efforts to assure the public and policymakers are aware of the problems of narrow insurer networks.  (HOD 2014-57) 

130.938:          Affordable Long Term Care Insurance

MSSNY’s Long Term Care Committee should meet regularly with state officials to work toward the creation of affordable long term care insurance options with a clearly defined premium and benefit structure. (HOD 2013-115 and 116)

130.939:          Initiation of the Physician Patient Relationship

MSSNY should establish as policy that the doctor patient relationship is formed when the physician first evaluates the patient and a consensual relationship has been initiated. (HOD 2013-101)

130.940:          Medical Liability Reform

MSSNY re-affirms Policies 130.965 and 130.975 and will continue to seek the enactment of comprehensive medical liability tort reform legislation, as well as new sources of revenue to subsidize physician medical liability insurance costs, including evaluating new strategies to achieve these ends. (HOD 2013-62, 63 and 64)

130.941:          Expand “Any Willing Provider” Legislation

MSSNY will continue to advocate for legislation that requires health insurers to include, within the network of any product offered by the insurer, any physician who is able to meet the terms of participation in that network. (HOD 2013-61; Reaffirmed HOD 2014-57; Reaffirmed HOD 2016-58)

130.942:          Repeal PPACA Restrictions on Physicians

MSSNY supports federal legislation to repeal provisions in PPACA that require physicians to enroll in Medicare, Medicaid and other governmentally sponsored health insurance programs as a condition of referring, ordering or prescribing for patients enrolled in these programs. MSSNY will forward this resolution to the AMA for consideration at its next annual meeting. (HOD 2013-54; Reaffirmed HOD 2014-53)

130.943:          Call for Action for Support of Continuation of CO-OP Applications

MSSNY will request the New York Congressional delegation to take appropriate action to restore necessary funding for new health insurance co-operatives, as had applied prior to enactment of the American Tax Relief Act of 2012, which eliminated this funding; and will urge the American Medical Association to work with the National Alliance of State Health Co-Ops (NASHCO) to request the US Congress and US Department of Health and Human Services to re-establish such funding as well. (HOD 2013-52)

130.944:          Excise Taxes on Health Insurance Policies

MSSNY supports the adoption of federal legislation to repeal the component of PPACA that imposes excise taxes on comprehensive health insurance policies starting in 2018. (HOD 2013-51)

130.945:          Surprise Fee in Patient Protection and Affordable Care Act (PPACA)

MSSNY should advocate that any proposed assessment on “issuers of insurance” (scheduled to commence in 2014 for a 3-year period) intended to fund a “risk adjustment program” to cushion insurers against any actual uncertainties surrounding the health status of the uninsured, not be passed along to consumers, and bring a resolution on same advocacy to the AMA. (HOD 2013-50)

130.946_         Appoint Task Force on Medical Liability Insurance

In addition to current advocacy efforts to achieve meaningful liability reform, MSSNY will work with the Cuomo administration to develop a Task Force on Medical Liability Reform with significant physician/MSSNY representation.  (HOD 2012-51)

130.947_         Expert Witness Program For New York State

MSSNY will work with the NYS Bar Association and the NYS Court System to develop a system to better assure appropriately qualified witnesses to testify in medical liability actions. (HOD 2012-52) 

130.948           Expression of Concerns Through AMA Regarding Implementation  of COOP Program

MSSNY will advise AMA that in implementing the COOP provisions of PPACA, the COOP advisory board crafted regulations that enabled an established issuer of insurance to benefit from start-up loans, thus defeating the intended purpose of those loans and depriving New Yorkers of a new issuer.

The Medical Society of the State of New York (MSSNY) will seek AMA advice or assistance in crafting a response to the action of the COOP advisory board that enabled an established issuer of insurance to benefit from start-up loans, thus depriving New Yorkers of a new issuer. (HOD 2012-204)

130.949           Cost Containment is the Antithesis to Performance Improvement

The Medical Society of the State of New York (MSSNY) opposes any health policy which supports capping payments because it is antithetic to innovation and true health care system reform.

MSSNY will urge the AMA to adopt as policy opposition to any health policy which seeks to cap payments because it is antithetic to innovation and true health care system reform. (HOD 2012-106)

130.950           Credentials for Doctors Reviewing Appeals to Insurers

MSSNY will advocate for a change in law or regulation which requires physicians who hear appeals regarding payment for imaging studies be licensed and actively practicing clinical medicine in New York State and that such company physician be of a specialty satisfactory to the appealing physician for a particular case. (HOD 2012-111)

130.951           Repeal of the Patient Protection and Affordable Care Act (PPACA)MSSNY will continue to work with the Federation of Medicine and the American Medical Association to advocate and achieve needed reforms of the many defects of the federal PPACA law so as to protect the primacy of the physician-patient relationship.  These needed changes include but are not limited to:

-repeal of the Independent Payment Advisory Board (IPAB);

-repeal of the Medicare Cost/Quality Index;

-repeal of the non-physician provider non-discrimination provision;

-enactment of comprehensive medical liability reform;

-enactment of long term Medicare physician payment reform including permitting patients to

privately contract with physicians not participating in the Medicare program;

-enactment of antitrust reform to permit independently practicing physicians to collectively

negotiate with health insurance companies; and

-expanding the use of health savings accounts as a means to provide health insurance

coverage.  (HOD 2011-68)

130.952           Medical Malpractice Research:

MSSNY, together with the American Medical Association, continue advocacy efforts to include the documented failures of the civil justice system; work to achieve enactment of proven reforms; and obtain funding for specific demonstration projects that hold promise to reduce medical liability claims and transitional costs.  (HOD 2011-52)

130.953           Medical Liability Reform

MSSNY supports legislation which would allow physicians to carry 1st tier insurance of $500,000/$1.5 million funded by physicians and that there would be a 2nd tier insurance of $1.0 million/$3.0 million funded by an insurance pool – said pool to be funded by a fee on every health insurance policy sold in New York State.  To insure the survivability of such a fund, the reforms to include:

  • Cap on non-economic damages of $250,000 per defendant with a total of $750,000.
  • Medical Courts.
  • A No-fault system for claims involving neurologically-impaired infants.
  • Medical expert witness reform.
  • Certificate of merit reform. (HOD 2011-51; Reaffirmed HOD 2016-61)

130.954           Tort Reform as a Major Priority:

MSSNY will continue (1) seeking the enactment of medical liability reform as one of its major priorities and (2) urging the AMA to continue strongly advocating for the enactment of medical liability.  (HOD 2010-66)

130.955           National Medical Liability Reform:

MSSNY’s position is that effective medical liability reform that will significantly lower health care costs by reducing defensive medicine and eliminating unnecessary litigation from the system should be part of any national health system reform. (Council 11/19/09)

130.956           MSSNY Position on Health System Reform:

MSSNY will identify and distribute for the benefit of its members:

  • Provisions in proposed HSR legislation that are consistent with AMA/MSSNY policy,

and are therefore supportable

  • Provisions in proposed HSR legislation that would render it inconsistent with

MSSNY/AMA policy and therefore unsupportable.

In the event that HR 3961 fails to garner the necessary support in Congress and/or that the U.S. Senate fails to support a permanent fix to the SGR, MSSNY should convene its Council or the Council Executive Committee to consider a statement in opposition of this failure, and, should a statement be developed in response to either the U.S. House of Representatives or the U.S. Senate’s failure to support a permanent fix to the SGR, that MSSNY promulgate an agenda which includes opposition to those HSR efforts that are inconsistent with the following seven AMA principles:

  • Health insurance coverage for all Americans
  • Insurance market reforms that expand choice of affordable coverage and eliminate denials for pre-existing conditions
  • Assurance that health care decisions will remain in the hands of patients and their physicians, not insurance companies or government officials
  • Investments and incentives for quality improvement and prevention and wellness initiatives
  • Repeal of the Medicare physician payment formula that triggers steep cuts and threaten seniors’ access to care
  • Implementation of medical liability reforms to reduce the cost of defensive medicine
  • Streamline and standardize insurance claims processing requirements to eliminate unnecessary costs and administrative burdens. (Council 11/19/09)

130.957           MSSNY Position on Medical Liability Reform:

MSSNY’s current position on Medical Liability Reform is to be amended to also include the following:

  • An “Early Disclosure” pathway consisting of: early disclosure of medical errors with non-discoverability of statements of remorse; an administrative compensatory reimbursement system for error induced damages; and development of an accurate means of data collection to facilitate learning and quality enhancement; and
  • A Medical Court pathway to be used to adjudicate medical liability claims where an early disclosure pathway is not used; with an administrative compensatory method of reimbursement for error induced damages; and development of an accurate means of data collection so as to facilitate learning and quality enhancement.

In addition, MSSNY will work with:

  • New York State licensed medical liability carriers and, as necessary, the Governor and the State Legislature, to establish a pilot program for early disclosure programs and medical courts.
    • New York State licensed medical liability carriers to determine if the early disclosure and medical court programs can be established in such a way as to assure the resolution or adjudication of claims within one year. (Council 11/19/09)

130.958           Government Officials, Proactive Policy and Retrospective Data:

MSSNY will (a) continue its advocacy efforts on various health policies, as articulated by the MSSNY Council and House of Delegates; and (b) continue to have ongoing discussions with state and federal officials about proactive ways to address immediate health issues, such as physician shortages and access to health care.  (HOD 2009-158)

130.959           Excess Liability Insurance:

MSSNY will ask medical liability insurance carriers to determine the cost of providing Excess medical malpractice insurance coverage to physicians in non-hospital settings.  (HOD 2009-72)

130.960           “Consent to Settle” Clause and Frivolous Lawsuits:

MSSNY will:

  1. seek to protect the ability of a physician to choose at the time of purchasing a medical liability insurance policy whether they want to retain the right to consent to a proposed settlement;
  1. work with the American Medical Association and other organizations to determine the impact of “consent” clauses, and non-New York State licensed carriers including Risk Retention Groups on the frequency of the initiation of non-meritorious medical liability claims;
  1. work to encourage medical liability carriers to be explicitly transparent in their pricing policies, including specifying costs for consent vs. non-consent policies;
  1. collect, collate, compare and publish up-to-date data regarding costs, clauses, and features of malpractice insurers doing business in New York State. (HOD 2009-51)

130.961           Compensation for Frivolous Lawsuits:

MSSNY to continue advocating for legislation to reduce the bringing of non-meritorious medical liability claims, including but not limited to revised Certificate of Merit rules, expert witness reform, and legislation to permit the creation of medical courts.  (HOD 2009-50)

130.962           Health Care as Economic Stimulus:

MSSNY advocate for increased health care spending (and oppose health care cuts) as an economic stimulus package, owing to its substantial impact on local, regional economies and Gross Domestic Product (GDP) in addition to the legacy of better health. (HOD 2008-211)

130.963           Mandated Clinical Practice Guidelines

MSSNY policy is to be established against any legislation mandating strict compliance with Clinical Practice Guidelines.  (HOD 2008-104)

 

130.964           Re-institution of the Property and Casualty Insurers’ Contribution to the Excess:

MSSNY will continue to vigorously support medical liability reform, including premium relief, and support Assembly A08991 and Senate S6131 which would create a medical malpractice underwriting association to remedy the existing unbalanced situation by bringing in much needed financial resources to help shoulder the fiscal burden of supporting this vitally important medical malpractice insurance market of last resort. (HOD 2008-95; Reaffirmed HOD 2016-250)

130.965           The High Cost of Medical Liability Insurance:

MSSNY is directed to:

  1. Place premium relief from the high cost of medical liability insurance as a top priority

for the Legislative Program for next year;

  1. Seek legislation to reduce the amount of medical liability insurance required to be

eligible for excess insurance coverage at no cost from $1.3 million to $1.0 million;

  1. Seek legislation for New York State to subsidize a percentage of the premium cost;
  2. Make every effort to reduce the cost of medical liability insurance for physicians in

New York State before the number of physicians practicing in New York State is reduced to a level that may cause delays in accessing and/or an inability to access health care, especially in high-risk specialties and/or rural areas currently near or at a crisis; and

  1. Work to assure that the Legislature appropriates sufficient funds to support the Excess Insurance Program.  (HOD 2008-94)

130.966           Universal Access to Healthcare:

MSSNY will await the final recommendations of the Task Force on Health System Reform and take action on those recommendations at the 2009 House of Delegates by directing its delegates to advocate and vote for a platform embodying those recommendations.

Also, MSSNY will direct its delegates to the American Medical Association Annual Meeting in 2009 to advocate and vote for a platform which embodies the recommendations approved by the MSSNY 2009 House of Delegates.  (HOD 2008-91)

130.967           Reform of the Civil Litigation and Medical Liability Insurance Systems in New York State:

MSSNY approved the comprehensive plan to reform the Civil Litigation and Medical Liability Insurance Systems in New York developed by:

American College of Obstetricians and Gynecologists – District II

Greater New York Hospital Association

Healthcare Association of New York State

Medical Society of the State of New York

New York Chapter, American College of Physicians

New York Chapter of the American College of Surgeons

The major components of the plan are as follows

  1. Medical Malpractice Civil Litigation Process Reform

Systemic Remedies

Immediate Remedies

  1. Financial Relief
  2. Quality and Outcome Improvement Measures

(More detailed information about the plan is available from MSSNY’s Division of Governmental Affairs.)  (Council 9/20/07)

130.968           The Role of Physicians in Health Care Reform in New York State:

MSSNY should seek practicing member physician involvement in health care policy and reform in the state, offering policies formulated by its Task Force on Health Care Reform, by vigorously petitioning, lobbying and conferencing with the Governor’s office and the Department of Health to be included as a key partner in any state-mandated health care reform program.  (HOD 2007-106)

130.969           Universal Health Care

MSSNY opposes funding universal health insurance through decreased reimbursement, or any tax on physicians.  (HOD 2007-105)

130.970           Unfair Billing of the Uninsured:

MSSNY will monitor the impact of newly enacted legislation designed to constrain what uninsured low income individuals must pay for services provided in a general hospital.  (HOD 2006-89; Reaffirmed HOD 2016)

130.971           Long Term Care – Quality Initiatives:

MSSNY adopts as policy that all medical directors in long term care/skilled nursing facilities be encouraged to take training which provides recognized education in medical direction and may lead to certification in medical direction.  (Council 9/21/05; Reaffirmed HOD 2015)

130.972           MSSNY Openness to Health Care System Reform:

MSSNY policy on health care system reform be that of consideration and study of all and any new proposals in the health care arena likely to benefit the general public and the medical profession.  (HOD 2005-202; Reaffirmed HOD 2015)

130.973           Method of Financing Long Term Care

MSSNY supports a change in the financing of long term care to remove it from the County Medicaid budget and turn it over to the state budget as it is with most other states.  (HOD 2004-259; Reaffirmed HOD 2014)

130.974           MSSNY’s #1 Legislative Priority:

MSSNY continue to notify the respective legislative bodies in Albany, as well as all licensed physicians in New York State, that changing the present medical malpractice situation and enacting meaningful tort reform is its number one legislative priority, and that it will devote whatever resources are necessary to accomplish this important endeavor.  That MSSNY be on record as supporting the statements concerning medical liability reform as articulated by President George W. Bush in his 2003 State of the Union address.  (HOD 2003-88; Reaffirmed HOD 2013)

130.975           MSSNY’s Actions Toward Tort Reform:

MSSNY continues to:  1) strongly support the efforts of New York physicians to communicate their outrage with the failure of the legislature to take meaningful action to resolve the medical liability crisis;  2) devote all necessary resources to assist physicians, hospital medical staffs and other physician organizations in advocating this position to all elected officials and key staff and  3) provide appropriate assistance to the various grassroots groups protesting the current system by providing legislative and legal information, distributing communications among the groups, coordinating public relations and rallying public opinion.  The goal of these activities to solidify legislative support for medical liability reform to include caps on awards for non-economic damages, limit the time for filing a medical liability claim and allocate damages fairly in proportion to a party’s degree of fault.  Physicians exercising their legal rights to demonstrate their political opinions be aware at all times of their professional responsibility to their patients, and continue to treat emergencies and provide urgent and continuing care for those under active management.  (HOD 2003-97; Reaffirmed HOD 2013 DGA)

130.976           Recent Increase in Medical Liability Insurance Coverage:

MSSNY will seek legislative relief from the recent increase in the amount of medical liability coverage needed for acquiring the excess medical liability coverage, and that the amount of medical liability insurance required of a physician remain at $1 million/$3 million to be eligible for excess medical liability coverage at no cost to the physician.      (HOD 2002-67; Reaffirmed HOD 2013)

130.977           Organize Task Force for Health Care in America:  SUNSET HOD 2013

130.978           Tort Reform:  SUNSET HOD 2013

130.979           Equal Fees for Panel Physicians and Non-Panel PhysiciansSunset HOD 2011

130.980           Federal Laws Controlling Medical Savings Accounts Should be Revisited:
                       Sunset HOD 2011

130.981           Education of Public Regarding MCOs and MSAs:

MSSNY will educate its members and the public to:  (a)  understand that managed care organizations (MCOs) must function primarily as business entities, and as such, make decisions based on cost and not necessarily based on the patient’s best interest in the eyes of the treating physician;  (b)  educate the public that through the minimization of the role of third party payors patients and physicians can have the professional relationship desired by both in which quality will be maximized and costs will be controlled; and  (c)  educate its members and the public that this result can be approached at present through Medical Savings Accounts (MSAs) and ultimately through tax equity for all buyers of medical care and medical coverage.  (HOD 1997-277; Reaffirmed HOD 2014)

130.982           Administration of MSAs:

MSSNY will encourage consumers to obtain their MSAs from providers such as banks, brokerage houses, and other fiduciaries, and not form insurers.  (HOD 1997-276; Reaffirmed HOD 2014)

130.983           Point of Service Plans For Group Insurance Policies:  SUNSET HOD 2014 — See 165.998

130.984           Malpractice Reform To Reduce The Number Of Frivolous Suits:

Medical Society of the State of New York will seek legislation amending the New York State Civil Practice law and Rules to require that the Certificate of Merit currently required in a malpractice action be signed by a physician actively practicing in the same specialty of medicine or surgery of a defendant who is the subject of the lawsuit and that the identity of such physician be provided to the defendant at the time such Certificate of Merit is executed.  (HOD 1996-61; Reaffirmed HOD 1997-62 & HOD 2000-76; Reaffirmed HOD 2014)

130.985           All Self-Insured Programs To Have Same Standards As Other Insurers:

Medical Society of the State of New York will petition the appropriated legislative bodies and regulatory agencies to mandate that all self-insured programs be held to the same requirements, coverages and other standards as those to which HMOs, commercial insurers and governmental insurers are held; and will petition the American Medical Association to urge appropriate legislative bodies and regulatory agencies to pursue similar legislation/regulation at the Federal level.  (HOD 1997-61; Reaffirmed HOD 2014)

130.986           Timely Return of Properly Endorsed This Party Payor Contracts to Participating Physicians:

The Medical Society of the State of New York will seek appropriate legislative or regulatory action to require that upon receipt of physician-signed contracts by the health maintenance organization or insurance plan for participation in such plans, the HMO or insurance plan must be required to return a fully executed contract to the physician within 30 days of completion of such organization’s credentialing of the physician.  Such legislation shall require the HMO or insurer to provide notice to the physician within 120 days of submission of the physician’s signed contract of any additional information necessary to the completion of the physician credentialing process; and shall require that HMOs or insurers shall have no more than 30 days from receipt of all necessary credentialing information to complete the credentialing process.  (HOD 1997-59; Reaffirm HOD 2014)

130.987           Health System Reform – MSSNY Principles

MSSNY is sensitive to the compelling circumstances generating the movement towards health care system reform in New York State and nationally.  The Society is cognizant of the need to control health care costs while advocating the provision of health insurance coverage to the entire population of this state, including our 2.5 million citizens who are currently uninsured.  While cost controls are the primary factor influencing the reform process, MSSNY believes that access and quality are equally essential objectives which must not be compromised by any planned system restructuring.  In fact, cost control cannot be achieved if either access or quality is not satisfactorily addressed.

MSSNY believes that eventual stability of the state health care delivery system must be fundamentally predicated upon:  (1)  Universal access to high quality care for all New Yorkers;  (2)  Redirection of economies derived from renovation of a flawed system with its significant inefficiencies and frequent misallocation of resources to a more cost-effective service delivery structure;  (3)  Finance reform in conjunction with a price competitive market-based pluralistic system;  (4)  Meaningful physician input concerning relevant key aspects of any system reform.

Consequently, MSSNY believes that the following principles should be embodied in any reform of the state health care delivery system:  (1)  All New Yorkers regardless of health and income status should have access to high quality, affordable and basic health care;  (2)  Comprehensive health care reform should be achieved through a collective partnership encompassing the consumer, business, labor, health provider, health insurance and government sectors which would build on the positive elements of our current pluralistic health care system;  (3)  An independent health care access oversight authority comprised of pertinent private and public sector representatives should be established to monitor and assess the quality of care provided under the reform;  (4)  Health system reform should provide sufficient tax and financial incentives to create an environment of consumer cost consciousness which would compel vigorous price competition among health care insurers;  (5)  Competition among insurers should be predicated on required offering of the standard benefits program developed under the auspices of the proposed independent health care access oversight authority;  (6)  Individuals should have the right and responsibility to obtain, at minimum a standard benefits package, and finance a portion of cost of their care according to their means.  State government and employer contributions should supplement the purchase of such insurance as appropriate, with tax incentives provided to employees and employers for the purchase of the lowest priced comparable coverage among insurers (as identified by the independent authority).  Coverage beyond the standard package may be procured at additional cost, but without tax relief for the purchaser;  (7)  State financing, coupled with the necessary federal Medicaid/Medicare waivers, should be provided for the purchase of a standard benefits package by the indigent, elderly, uninsured and unemployed;  (8)  Health insurance system reform should be designed to:  (a)  Aid small business in the provision of health insurance to their employees;  (b)  Promote community rating;  (c)  Eliminate preexisting condition exclusions;  (d)  Guarantee renewability and portability;  (e)  Control premium increases;  (f)  Guarantee consumer choice of insurer, inclusive of programs providing freedom of choice of physicians;  (9)  Medical liability tort reform, including limitations on non-economic damages, should be enacted in concert with health care system restructuring to mitigate the costly practice of defensive medicine, while continuing to protect the legitimate interests of the patient community;  (10)  Practice parameters should be developed by physicians experts as useful educational tools for assuring the delivery of quality care and providing an affirmative defense in legal actions premised upon physician negligence;  (11)  Electronic claims processing (unrelated to a single payor authority) in conjunction with the development of a uniform claim form should be achieved in an effort to mitigate the current high administrative costs of health insurance operations;  (12)  Reimbursements for a defined service should be the same regardless of the site of that service (office, home, hospital settings, etc.) thereby establishing ambulatory care payment parity;  (13)  The residents of New York State should assume greater responsibility for their health by the imposition of financial sanctions directed toward mitigating unhealthy behaviors, taking appropriate preventive measures, and making conscientious cost effective determinations concerning the utilization of health care services;  (14)  The system must be structured to induce all insurers to function in the most cost-effective manner possible so as to ensure the mitigation of administrative costs, and application of the maximum amount possible of the premium dollar to health care benefits;  (15)  All providers of health care should be committed to adhering to the highest standards in the provision of patient care and interaction with health insurers.  (16)  Organized medicine, as represented by MSSNY, should be authorized to represent physician interests in negotiating the establishment of fees with insurers and other payors.  (17)  MSSNY is committed to organize physicians into an integrated risk-sharing entity in order to offer an alternative to capitated plans and to permit private practicing physicians to compete effectively in the managed care/managed competition arena in both the public and private payor market.  (Council 6/3/93; Reaffirmed HOD 01-256; Reaffirmed HOD 2011 and also Reaffirmed AMA Substitute Resolution 203, Health System Reform Legislation (below):

RESOLVED, That our American Medical Association is committed to working with Congress, the Administration, and other stakeholders to achieve enactment of health system reforms that include the following seven critical components of AMA policy:

  • Health insurance coverage for all Americans;
    • Insurance market reforms that expand choice of affordable coverage and
    • eliminate denials for pre-existing conditions or due to arbitrary caps;
  • Assurance that health care decisions will remain in the hands of
  • patients and their physicians, not insurance companies or government
  • officials;
  • Investments and incentives for quality improvement and prevention
  • and wellness initiatives;
  • Repeal of the Medicare physician payment formula that triggers steep
  • cuts and threaten seniors’ access to care;
  • Implementation of medical liability reforms to reduce the cost of
  • defensive medicine; and
  • Streamline and standardize insurance claims processing requirements
  • to eliminate unnecessary costs and administrative burdens; and be it
  • further

RESOLVED, That our American Medical Association advocate that elimination of denials due to pre-existing conditions is understood to include rescission of insurance coverage for reasons not related to fraudulent representation; and be it further

RESOLVED, That our American Medical Association House of Delegates supports AMA leadership in their unwavering and bold efforts to promote AMA policies for health system reform in the United States; and be it further

RESOLVED, That our American Medical Association support health system reform alternatives that are consistent with AMA policies concerning pluralism, freedom of choice, freedom of practice, and universal access for patients; and be it further

RESOLVED, That it is American Medical Association policy that insurance coverage options offered in a health insurance exchange be self-supporting, have uniform solvency requirements; not receive special advantages from government subsidies; include payment rates established through meaningful negotiations and contracts; not require provider participation; and not restrict enrollees’ access to out-of-network physicians; and be it further

RESOLVED, That our AMA actively and publicly support the inclusion in health system reform legislation the right of patients and physicians to privately contract, without penalty to patient or physician; and be it further

RESOLVED, That our AMA actively and publicly oppose the Independent Medicare Commission (or other similar construct), which would take Medicare payment policy out of the hands of Congress and place it under the control of a group of unelected individuals; and be it further

RESOLVED, That our AMA actively and publicly oppose, in accordance with AMA policy, inclusion of the following provisions in health system reform legislation: 2

  • Reduced payments to physicians for failing to report quality data when
  • there is evidence that widespread operational problems still have not been
  • corrected by the Centers for Medicare and Medicaid Services;
  • Medicare payment rate cuts mandated by a commission that would create a
  • double-jeopardy situation for physicians who are already subject to an
  • expenditure target and potential payment reductions under the Medicare
  • physician payment system;
  • Medicare payments cuts for higher utilization with no operational
  • mechanism to assure that the Centers for Medicare and Medicaid Services
  • can report accurate information that is properly attributed and risk
  • adjusted;
  • Redistributed Medicare payments among providers based on outcomes,
  • quality, and risk-adjustment measurements that are not scientifically valid,
  • verifiable and accurate;
  • Medicare payment cuts for all physician services to partially offset
  • bonuses from one specialty to another; and
  • Arbitrary restrictions on physicians who refer Medicare patients to high
  • quality facilities in which they have an ownership interest; and be it further

RESOLVED, That our American Medical Association continue to actively engage grassroots physicians and physicians in training in collaboration with the state medical and national specialty societies to contact their Members of Congress, and that the grassroots message communicate our AMA’s position based on AMA policy; and be it further

RESOLVED, That our American Medical Association use the most effective media event or campaign to outline what physicians and patients need from health system reform; and be it further

RESOLVED, That national health system reform must include replacing the sustainable growth rate (SGR) with a Medicare physician payment system that automatically keeps pace with the cost of running a practice and is backed by a fair, stable funding formula, and that the AMA initiate a “call to action” with the Federation to advance this goal; and be it further

RESOLVED, That creation of a new single payer, government-run health care system is not in the best interest of the country and must not be part of national health system reform; and be it further

RESOLVED, That effective medical liability reform that will significantly lower health care costs by reducing defensive medicine and eliminating unnecessary litigation from the system should be part of any national health system reform; and be it further

RESOLVED, That our American Medical Association reaffirm AMA policy H-460.909 Comparative Effectiveness Research.

(Note:  Also Filed for Information is the Final Report of MSSNY’s Subcommittee on Health System Reform, chaired by Dr. Robert Scher, which was adopted by the MSSNY House of Delegates.)

130.988           Medical Savings Accounts

MSSNY vigorously supports the introductions of Medical Savings Accounts (MSAs) in New York State and will support legislation such as that embodied in State Assembly Bill 6249A and its companion Senate Bill 69A calling for the establishment of tax-favored Supplemental Insurance Accounts (which essentially embody the MSA concept), subject to subcommittee interaction with State legislators for an opportunity to:  (a)  provide additional MSSNY input and possible suggested modifications to the aforementioned Assembly/State bills;  (b)  exchange views with hopeful enlistment of legislative support.

MSSNY supports expansion of the subcommittee charge to timely interact with representatives of the insurance, banking and business sectors as well as the Council on Affordable Health Insurance for educational purposes and for an in-depth investigation and assessment of:  (a)  the economic ramifications of MSAs;  (b)  the level of insurer/consumer interest in MSAs;  (c)  alternatives or modifications to the basic MSA concept as may be appropriate, necessary and feasible.

MSSNY vigorously supports the right of individuals to select their own health insurance plan and to receive the same tax-exempt treatment for individually purchased insurance as for employer-purchased coverage.  (Council 12/19/96)

MSSNY will seek state and federal legislation that would enable individuals to create medical savings accounts for health care purposes which would encompass the concepts of utilization of pretax dollars, tax-free accumulations, and non-penalized withdrawals for health care and other related purposes.  (HOD 1995-85; Policy Reaffirmed HOD 2014)

130.989           Funding Academic Medicine and Teaching HospitalsSUNSET HOD 2014

130.990           Contracting, Independent Patient-Physician:

MSSNY endorses the concept of the inalienable right of physicians and their patients to privately contract for the provision of and payment for medical services, and will urge the American Medical Association not to participate in or endorse any legislation which does not guarantee this right.  (HOD 1994-60; Reaffirmed HOD 2000-262; Reaffirmed HOD 2014)

130.991           Financial Disclosure Requirements by Health Maintenance Organizations (HMOs), Revision of:

MSSNY supports legislation and/or regulation to require that all managed care entities or organizations incorporate into their annual financial disclosure statements all disbursements made by such entities or organizations for all administrative purposes, marketing, physician, hospital, pharmacy and ancillary health care provider services, as well as any surplus funds, profits or dividends declared.  (HOD 1994-56; Reaffirmed HOD 2014)

130.992           Reimbursement for Medically Necessary Emergent Services Provided by Non-participating Managed Care Physicians and Hospitals:

MSSNY will seek appropriate legislation which would require all managed care entities operating in the State of New York to reimburse physicians and hospitals for medically necessary emergency  services provided in good faith to managed care subscribers, without consideration of participation status.  (HOD 1994-84; Reaffirmed HOD 2014)

 

130.993           Medical Liability Reform:

MSSNY reaffirms its support for the inclusion of medical liability reform within the context of state and/or federal health system reform which shall include but not be limited to the following:  (1)  Enactment of a $250,000 cap on the non-economic component of a medical liability award.  (2)  Extension of the excess liability insurance program until fundamental tort reforms is achieved.  (3)  The establishment of a no-fault administrative compensation system for impaired newborns. (4)  Legislation which would provide an affirmative defense to any cause of action for physicians adhering to appropriately established practice guidelines provided, however, non-adherence to practice guidelines shall not be used as evidence that the physician failed to meet the accepted standards of care.  (HOD 1994-86; Reaffirmed HOD 2008-96; Reaffirmed HOD 2016-61 & 250)

130.994           “Willing Provider” Legislation:

MSSNY supports Federal and/or State legislation or regulation modeled after the recommendations contained in Report 25 of the American Medical Association adopted by the AMA at its 1993 Interim Meeting which report affirms:  (1)  The patient’s right to choose his or her physician.  (2)  The physician’s primary role as patient advocate.  (3)  The physician’s right to apply to any health plan or network and to have that application approved if it comports with physician-developed objective criteria based on professional qualifications, competence and quality of care.  (4)  That managed care entities and organizations and third party payers be required to disclose to physicians applying to a plan the selection criteria used to select, retain or exclude a physician from a managed care plan, including the criteria used to determine the number, geographic distribution and specialties of physicians needed.  (5)  That in those cases in which economic issues may be used for consideration of sanction or dismissal, the physician participating in the plan should have the right to receive profile information and education and that no action be taken without due process.  (6)  That any federal effort to preempt state “any willing provider” laws be opposed.  (7)  Support for appropriate changes in relevant antitrust laws to allow physicians and physician organizations to engage in group negotiation with managed care plans.

MSSNY supports legislation that would protect physicians from dismissal from health care plans and/or the imposition of sanctions by health care plan administrators without due process, and will reach out to and seek the cooperation of ancillary providers and relevant consumer organizations to elicit their support of legislation and regulation which prohibits managed care entities and organizations, insurance companies or other similar organizations from unreasonably inhibiting provider access to their patients.  (HOD 1994-57; Reaffirmed by Council 11/29/2012 in lieu of 2012-260)

130.995           Long Term Care:  SUNSET HOD 2014

130.996           Single Payor Reimbursement System – Opposition To

MSSNY is opposed to universal health care proposals with single-payor reimbursement systems.  It reaffirms the position reflected in its Universal Health Plan (UHP) Proposal for improving the U.S. Health Care System which call for:  (1)  Retention of the present multiple payor system with tighter oversight mechanisms to enhance administrative controls and cost efficiencies;  (2)  Free-market competition as a stabilizing factor in choosing among a multiplicity of health insurers offering a standard and appropriate benefits package.  (HOD 1992-13; Reaffirmed HOD 2014)

130.997           Maternal and Infant Care

MSSNY supports universal access to maternal and infant care; to family planning, pre-pregnancy related health care evaluation, pregnancy diagnosis, nutritional support, substance abuse counseling, full pregnancy related services, labor and delivery, postpartum evaluation, neonatal care, and infant care. (HOD 92-56; Modified and reaffirmed HOD 2014)

130.998           Age as Sole Criteria in Determining Allocation of Health Care Resources

MSSNY supports the position that chronological age should not be the sole criteria in determining the allocation of health care resources.  (Council 7/21/88; Reaffirmed HOD 2013)

130.999           Capitated Gatekeeper Reimbursement Policy:

Since the potential for abuse exists under capitated reimbursement systems through the withholding of services, the Medical Society of the State of New York strongly opposes any system of health care delivery which would limit services based primarily on financial consideration.  (HOD 1986-14; Reaffirmed HOD 2013)

135.000      HOME HEALTH CARE: (See also Reimbursement, 265.000)

 

135.993           Taskforce on Home Care Services

The Medical Society of the State of New York (MSSNY) and the Home Care Association of New York State (HCA) shall form a taskforce to collaborate and assess issues relating to:

(1) community physician involvement in the development of care plans for home care

services;

(2) the transmission of clinical information;

(3) non-reimbursement resulting from delayed requests for physician orders;

(4) and administrative inefficiencies.

The results and recommendations of the taskforce and collaboration between MSSNY and HCA shall be reported to the Long Term Care Subcommittee of the Quality Committee for further action such as educational, regulatory or legislative changes. (HOD 2016-118)

135.994:          Support of Three Point Legislative Plan for Home Care

MSSNY backs the Three Point Plan to Support and Ensure Success Of State Redesign Efforts (transition support, regulatory relief, and stable fiscal environment) and supports efforts to keep MSSNY’s Long Term Care Subcommittee members informed of the progress being made in this endeavor.  (HOD 2013-114)

135.995           Home Attendant Ability to Instill Eye Drops:

MSSNY to petition the appropriate authorities to allow home attendants to instill eye drops in their patients. (HOD 2008-107)

135.996           Home Health Care Services in New York State

The MSSNY Council adopted a position statement of Home Health Care Services in New York State which called on the State to develop a Home Care Policy Plan and to address the critical manpower shortage in home care.  The position statement endorsed the following principles:  (1)  Home care enhances the quality of life, promoting independence and the availability of choice;  (2)  Home care should be accessible and available to all persons regard-less of their financial ability to pay;  (3)  Home care should maintain reasonable standards of quality care and be fully integrated with all the other components of the health care delivery system;  (4)  All orders emanating from home care agencies that pertain to the care and management of the individual patient should be under the direct supervision and control of the attending physician.  This alludes to all orders for any type of medical care rendered to patients, particularly to those confined to the home.  It is the responsibility of the individual physician to see that such orders are completely executed.  (Council 7/21/88; Reaffirmed HOD 2013)

135.997           Tax Deduction for Long Term Home Health Care

MSSNY supports legislation which would provide a New York State and federal tax deduction for individuals rendering home care to family members with a long term illness.  (HOD 1988-79; Reaffirmed HOD 2013)

135.998           Elderly – Home Health Care

MSSNY supports the concept that reimbursement for home health care for the elderly be provided on a twenty-four hour a day basis, seven days a week, if required for the adequate care of the patient and to prevent the institutionalization of such patient for reasons not requiring institutional care.  (HOD 1980-37; Reaffirmed HOD 2013)

135.999           Home Health Care Services:

MSSNY encourages the stimulation of physician interest in, and acceptance of home care as an integral part of the overall continuum of medical care.  We also emphasize the need for medical schools and internship programs to educate medical students, interns, residents, and practicing physicians in the value and proper use of home health care programs.  Hospital boards and medical staffs should encourage community interest in support of home health care programs.  Community health planning agencies should have representation from organizations concerned with providing home care services; and practicing physicians should involve themselves in developing home health care programs along with community health planning agencies.

MSSNY supports the concept that all home health agencies, voluntary or proprietary, should be subject to the same controls, regulations, and standards.  MSSNY also supports the concept that the physician is responsible for monitoring the home health care of his patients, or for the transferal of this responsibility to another physician.  (Council 9/14/77; Reaffirmed HOD 2013)

140.000      HOMELESS SHELTERS:

140.999        Armories as Shelters for the HomelessSUNSET HOD 2014

145.000      HOSPICE AND PALLIATIVE CARE:

145.996           Maintaining and Developing High Quality Hospice and Palliative Care

The Medical Society of the State of New York recognizes that there is a shortage of physicians in geriatrics, hospice and palliative care.  By submitting this resolution to the AMA House of Delegates, will urge the American Medical Association to work with the various national medical specialty organizations to petition the American Board of Medical Specialties to develop alternative pathways to board certification for physicians with high quality experience and additional education to sit for the boards in hospice, palliative care, and in geriatric medicine.  (HOD 2014-163) 

145.997           Palliative Care Services

MSSNY supports public education regarding palliative care and seeks state legislation/regulation to provide appropriate reimbursement for evidenced-based palliative care services.  (HOD 2005-160; Reaffirmed HOD 2015)

145.998           Medicare Hospice Benefits for Nursing Home ResidentsSUNSET HOD 2014

145.999           Hospice Care

Hospice is provided at home or in freestanding hospice centers, nursing homes and other long term care facilities.  Hospice is a concept of patient and family centered, designed to meet the physical, psychological, spiritual, and social needs of terminally ill patients and their families.  This care shall be rendered by a physician-led inter-disciplinary team.

The goals of hospice care are:  1)  Manages the patient’s pain and symptoms; 2)  Assists the patient with the emotional, psychosocial and spiritual aspects of dying; 3)  Provides needed drugs, medical supplies and equipment;  4)To support the family on how to care for the patient  (5) Provides bereavement care and counseling to surviving family and friends.  (Council 6/21/79; Modified and Reaffirmed HOD 2013)

150.000      HOSPITALS:

                     (See also Clinical Judgment 40.000; Ethics, 95.000; Medical Examiner System, 185.000; Nuclear War, Weapons and Terrorism, 215.000; Practice Management, 240.000; Reimbursement, 265.000; Vaccines, 312.000; Weight Management & Promotion of Healthy Lifestyles, 320.000)

150.966           Hospital Closures

MSSNY will ask the New York State Legislature to enact laws that require hospitals which are going to be closed or significantly change the level of clinical services, to develop a clinical impact statement and that the statement be presented at a public hearing run by the Health Department; that this clinical impact statement be used to document the diminution in services and outline ways that the community can be compensated or continue to receive these services in another venue; and that the public should have a chance to comment on this document, with the Health Department as the final arbiter if the removal of the services creates a danger to the community.  (HOD 2014-111) 

150.967           Taskforce on Hospital Mergers

The Medical Society of the State of New York will solicit relevant agencies to routinely engage MSSNY as a significant stakeholder in the evaluation of hospital mergers or closures regarding characteristics including, but not limited to:

  1. Maintenance of patient choice and market competition
  2. Cultural sensitivity and minority and community representation among key personnel
  3. Compliance with MSSNY Position Statement 235.996
  4. Provision of charity care consistent with the designation as a non-profit
  5. Assurance of adequate access to primary and subspecialty care
  6. Ability to achieve and maintain high scores on measures of patient satisfaction, patient safety and quality metrics
  7. Preservation of the continuity of the physician-patient relationship
  8. Effect on graduate and undergraduate medical education.  (HOD 2014-201)

150.968           Operating Room Quiet Zones

The Medical Society of the State of New York will work with the Healthcare Association of New York State and the Greater New York Hospital Association to develop policies regarding the use of electronic devices in operating rooms and procedure rooms to ensure patient safety. (HOD 2012-150)

150.969           Stop Closure of Kingsboro Psychiatric Center as Recommended by the Berger
                         Commission

MSSNY will advocate that Kingsboro Psychiatric Center in Brooklyn stay open and not move to South Beach Psychiatric Center in Richmond County for the best interests of the patients and their families. (HOD 2012-113)

150.970           Compensation for Emergency Department Coverage

MSSNY recommends that hospitals utilizing voluntary physicians to provide coverage for emergency departments provide appropriate compensation for these services in a manner consistent with Advisory Opinions issued by the Office of the Inspector General (OIG) and, also, that voluntary physicians should not be required by hospitals to provide emergency department coverage without compensation.  (HOD 2011-111)

150.971           HHS and Hospital-Acquired Conditions:

MSSNY will ask the American Medical Association to work with the Centers for Medicare & Medicaid Services to delay the implementation of Section 5001(c) of the Deficit Reduction Act (DRA) of 2005 in order to eliminate from the list those conditions that cannot be fully prevented even with the application of the best evidence-based guidelines.  (HOD 2008-258)

150.972           Gain-sharing:

MSSNY will ask the American Medical Association to study and prepare a report on gain-sharing programs.  (HOD 2008-206)

150.973           Unified System for Hospital Re-credentialing in New York State:

MSSNY will work for legislation requiring all New York State hospitals to use the same standard re-credentialing form, and require the same standard data and/or materials for re-credentialing.

MSSNY will work for legislation providing that hospital re-credentialing forms should require the physician to fill out only information that has changed since the previous submission.  (HOD 2002-269; Reaffirmed HOD 2013)

150.974           Hospital Overcrowding; Developing Statewide Solutions:

MSSNY will urge the New York State Department of Health, with input from MSSNY and other interested parties, to analyze data on hospital overcrowding, and make this data available for local initiatives, including public relations and media tactics, and other efforts to mitigate the hospital overcrowding problem.  (HOD 2002-78; Reaffirmed HOD 2013)

150.975           MSSNY to Take All Appropriate Measures to Facilitate Transfers of Non-acute Patients to Physicians’ Offices:

MSSNY should take all appropriate measures to allow hospital emergency departments to facilitate the transfer of non-acute patients to physicians’ offices in appropriate situations.  (HOD 2000-77; Reaffirmed HOD 2014)

150.976           Opposition to the Criminalization of the Infractions of State Statutes and Regulations Regarding Post Graduate Supervision and Staffing:

MSSNY will notify all teaching hospitals of the importance of adherence to the requirements of State Statutes and Regulations regarding Post Graduate Supervision and Staffing.  MSSNY shall continue to oppose the Criminalization of good faith medical judgment, and each teaching institution required to comply with State Statutes and Regulations Regarding Post Graduate Supervision and Staffing regulations shall provide on a yearly basis a copy of those regulations to each house officer and each attending physician.  (HOD 1999-172; Reaffirmed HOD 2014)

150.977           Prohibit Institutions from Mandating In-House Testing:

MSSNY will seek measures to prohibit mandatory in-hospital pre-operative testing when those tests, including but not limited to blood and urine, EKGs, chest X-rays, etc are performed in a qualified physician’s office or in a state-and/or CLIA-accredited facility.  (HOD 1998-126; Reaffirmed HOD 2014)

150.978           For Profit Hospitals and Nursing Homes:

MSSNY will vigorously support current law prohibiting for-profit businesses from entering the New York hospital and nursing home market.  (Council 12/18/97; Reaffirmed HOD 2014)

150.979           In-House Testing, Prohibition of Institutions from Mandating

MSSNY believes that institutions should allow physicians to perform any mandated pre-operative testing outside the institution and will encourage institutions to adopt this policy.  (HOD 1996-126; Reaffirmed 2014)

150.980           Services, Provision of on a Seven Day A Week Basis

MSSNY supports the provision of all appropriate services on a seven day a week basis to assure timely evaluation treatment and safe discharge of patients and will encourage hospitals to comply with this policy.  (HOD 1996-127; Reaffirmed HOD 2014)

150.981           Maternity and Family Leave for Hospital Medical Staff, Including Residency Programs in New York State

The position of the Medical Society of  the State of New York regarding leave policies for physicians in practice or residency training includes as follows:

(a)  MSSNY urges medical schools, residency training programs, medical specialty boards, the Accreditation Council on Graduate Medical Education and medical group practices to incorporate and/or encourage development of written leave policies including parental leave, family leave and medical leave;

(b)  Residency program directors and group practice administrators should review federal and state law for guidance in developing policies for parental, family and medical leave;

(c)  Physicians who are unable to work because of disability due to pregnancy, childbirth and other related medical conditions should be entitled to such leave and other benefits on the same basis as other physicians who are temporarily disabled for other medical reasons;  (d)  Residency programs and group practices should develop written policies on parental leave, family leave and medical leave for physicians.  Such written policies should include the following elements:

leave policy for birth or adoption;

duration of leave allowed before and after delivery;

category of leave credited (e.g. sick, vacation, parental, unpaid leave, short term disability);

whether leave is paid or unpaid;

whether provision is made for continuation of insurance benefits during leave and who pays for premiums;

whether sick leave and vacation time may be accrued from year to year or used in advance

Residency program policies should also include:

extended leave for resident physicians with extraordinary and long-term personal or family medical tragedies for period of up to one year without loss of previously accepted residency positions, for devastating conditions such as pregnancy which threaten maternal or fetal life;

how time can be made up in order to be considered board eligible;

whether make-up time will be paid;

what period of leave would result in a resident physician being required to complete an extra or delayed year of training;

whether schedule accommodations are allowed, such as reduced hours, no night call, modified rotation schedules and permanent part-time scheduling.

(e)  Staffing levels and scheduling are encouraged to be flexible enough to allow for coverage without creating intolerable increases in other physicians’ workloads, particularly in residence programs; and  (f)  Physicians should be able to return to their practices or training programs after taking parental leave, family leave or medical leave without the loss of status.  (Council 3/9/95; Amended HOD 1997-180; Reaffirmed HOD 2014)

150.982           Guidelines Regarding the Role of Medical Directors in New York State:

MSSNY supports the following Guidelines Regarding the Role of the Hospital Medical Director:

(1)  The hospital governing body, management and medical staff should jointly determine if there is a need to employ a medical director; establish the purpose, duties, and responsibilities of this position; establish the qualifications for this position; and provide a mechanism for medical staff input into the selection, evaluation and termination of the hospital medical director;

(2)  The organized medical staff should maintain overall responsibility for the quality of the professional services provided by individuals with clinical privileges and should have the responsibility of reporting to the governing body; and

(3)  Government regulations which mandate that a hospital medical director has authority over the medical staffs should be repealed.

MSSNY will seek modification of existing laws and regulations consistent with these guidelines.  (HOD 1995-72; Reaffirmed HOD 2014)

150.983           Faculty/Staff Appointments at Medical Schools:

MSSNY supports having the New York State Department of Health develop regulations or legislation that would prevent a hospital from requiring a member of its voluntary staff to resign or accept a faculty appointment at a medial school as a condition of appointment to the medical staff, and is petitioning the New York State Department of Education to take all steps necessary to encourage the development of an adjunct faculty line at each medical school which would permit physicians to hold more than one medical school faculty appointment.  (HOD 1993-131; Modified and reaffirmed HOD 2014)

MSSNY adopted the policy that it is inappropriate for any hospital to require a member of its voluntary staff to resign a faculty appointment at a medical school as a condition of appointment or reappointment.  MSSNY supports the development of an adjunct faculty line at each medical school in New York State that could be used to permit physicians to hold more than one medical school faculty appointment.  It has adopted as policy that it is inappropriate for a hospital or medical school to deny a physician an appointment or reappointment to its voluntary staff because that physician already holds a position at another medical school.  (HOD 1992-88; Reaffirmed HOD 2014)

150.984           Outpatient Medical Services

MSSNY is seeking legislation to provide that practitioners whose practices are supported, sponsored by and financially beneficial to hospital controlled satellite diagnostic and therapeutic facilities be held to the same self-referral standards to which the community-based practitioners are held.  (HOD 1993-77; Reaffirmed HOD 2014)

150.985           Incident Reports

MSSNY is working with the Hospital Association of New York State to ensure that a copy of a hospital incident report which has been forwarded to the New York State Department of Health be sent to any physician whose name is included in such incident report.  MSSNY is seeking to ensure that physician identifying information included in hospital incident reports submitted to the New York State Department of Health remain confidential and not be publicly disclosed, as well as seeking to ensure that all information developed by review of incidents required to be reported including, but not limited to “Statements of Deficiency” be covered under existing New York State confidentiality statutes and not be subject to disclosure through the Freedom of Information Law (FOIL).  (HOD 1992-40; Reaffirmed HOD 2014)

150.986           Physical Examination for Physicians (Annual)

MSSNY continues to meet with the Department of Health and other interested parties to clarify existing issues pertaining to the physical examination requirements under Section 405.(b)(10) of the Health Department regulations.  MSSNY takes the following position with regard to the physical examination requirements:

(1)  Physicians should have the option of going to his/her personal physician for the physical examination;

(2)  If the physician opts to have the physical examination performed by the personal physician, the medical records pertaining to the physical examination should be retained in the office of the personal physician.

(3)  The attestation form which the hospital must retain to document the physical examination should be standardized.

MSSNY should be involved in the development of an attestation form.  (HOD 1991-91; Reaffirmed HOD 2014)

150.987           Medical Staff Involvement in Development of Plan of Correction:

MSSNY adopted the policy that a hospital medical staff must be appropriately involved in the development of a “Plan of Correction” as it pertains to the medical staff.  Such involvement should be consistent with existing hospital medical staff Bylaws, rules and regulations. Hospital medical staffs were encouraged to amend their Bylaws, if necessary, to establish a procedure to ensure appropriate medical staff input into the development of a “Plan of Correction.”  (HOD 1991-105; Reaffirmed HOD 2014)

150.988           Economic Credentialing and Medical Staff Privileges:

It is the position of MSSNY that:

(1)  No hospital or ambulatory facility shall curtail, restrict, or terminate the medical staff privileges of any physician without adherence to established procedures set forth in the medical staff Bylaws, and only after the accordance of due process rights pursuant to the procedures specified in the Federal Health Care Quality Improvement Act of 1986, or in accordance with provisions of the hospital or ambulatory facility medical staff Bylaws; and  (2)  No hospital or ambulatory facility shall curtail, restrict, or terminate the medical staff privileges of any physician based upon economic criteria unrelated to the quality of patient care; and

(3)  No hospital ambulatory facility shall solicit, require, or accept any payment as direct or indirect consideration for the awarding or granting by the hospital or ambulatory facility of the right to exercise medical staff privileges.  This prohibition shall not apply to required payment of medical staff dues or medical society dues that may be required of all members of the hospital or ambulatory facility medical staff.  (HOD 92-33; reaffirmed HOD 2014)

MSSNY’s Hospital Medical Staff Section developed a MSSNY Policy Paper on Economic Credentialing and Exclusive Contracts which was approved by Council on July 23, 1992.  The Policy Paper is available, upon request, at the Society Headquarters in Lake Success.  MSSNY affirmed the concept that the credentialing of physicians for medical staff appointment or reappointment should be based solely on issues of competency, training and quality of patient care.  The Society is seeking regulatory or legislative remedies to assure that only those with appropriate medical training, experience and ongoing clinical expertise will have the ability to establish standards of care and measure practice by these standards.  MSSNY has communicated to the Hospital Association of the State of New York, its component associations and all other appropriate and interested parties its concern over the use of an individual physician’s economic performance data which is being generated by hospitals in an effort to link charges, cost and clinical outcome as a major parameter, in and of itself, for the purposes of credentialing and re-appointing physicians.  Hospital medical staff physicians and their leadership were informed by MSSNY to take precautions against any hospital initiative aimed at restructuring medical staff Bylaws which would emphasize economics and which could ultimately undermine quality of care.  (HOD 1991-67; Reaffirmed HOD 2014)

150.989           Governing Boards – Medical Staff Physician Representation:  

In light of recent changes to revised New York State Hospital Code (Part 405) and the resulting increase of hospital governing boards’ focus on quality assurance and clinical resource allocation, the Medical Society of the State of New York reaffirmed its positions and urged hospitals in New York State to appoint active medical staff members as full voting staff members of hospital governing boards.  (HOD 1990-20; Reaffirmed HOD 2013)

MSSNY is seeking enactment of legislation specifically authorizing physicians who are members of the medical staffs of municipal hospitals to serve on the governing body of such municipal hospitals, and is encouraging physicians who are members of medical staffs of all hospitals to seek to serve on the governing bodies of their hospitals.  (HOD 1988-82; Reaffirmed HOD 2013)

MSSNY recognizes the essential close working relationship that must exist between hospital governing bodies and medical staffs to ensure the delivery of optimal quality medical care to all patients served by hospitals.  To accomplish this, MSSNY strongly endorses the concept of practicing physician representatives from the medical staffs serving on hospital governing boards with voice and vote, to provide expertise and guidance concerning the development of medical care priorities.  (Council 11/14/85; Reaffirmed HOD 2013)

150.990           Certificate of Need

MSSNY has insisted on the elimination of the technique utilized by the New York State Department of Health of withholding or delaying Certificates of Need from hospitals (and other institutions) until compliance with other State Health Department regulations is obtained.  It is the position of MSSNY that the public be advised of the medical profession’s concern about this abuse of authority.  (HOD 1989-15; Reaffirmed HOD 2013)

150.991           Physician CredentialingSUNSET HOD 2013

150.992           Bed Reductions

MSSNY vigorously opposes any reduction of hospital beds throughout New York State unless very specific rationale supports it.  (HOD 1987-31; Reaffirmed HOD 2013)

150.993           Newborn – Resuscitation ofSUNSET HOD 2013

150.994           Termination of Hospital Privileges Based on Age of Physician

MSSNY opposes mandatory termination of hospital privileges based solely upon the age of the physician, and takes the position that age should not be used as a criterion in judging the character or competency of the physician.  (HOD 1986-23; Reaffirmed HOD 2013)

150.995           Preadmission Review

MSSNY is in agreement with the American Medical Association policy to oppose mandated blanket hospital preadmission review for all patients, or for specified categories of patients, by government, other payors or hospitals, while encouraging physician-directed peer review organizations to consider the implementation of focused preadmission review on a voluntary basis.  The MSSNY promulgated the following sample Guidelines for all third party payors or insurers in the matter of preadmission certification and review in this State Preadmission Certification and Review Guidelines:

(1)  The physician/patient relationship must remain intact and must not be disturbed by interference from any entity, including third party insurer.

(2)  The quality of health care delivered must remain at the highest level and not be affected by health insurance mandated policies and procedures.

(3)  There shall be direct and continuing communications by health insurers to physicians and insureds regarding prior authorization requirements; it shall be the responsibility of the insured or insurer to notify physicians when there are any pre-authorization or other technical contract requirements connected with the rendering of specific services.

(4)  In situations where the diagnosis, proposed plan of treatment, and anticipated length of hospital stay is questioned, it must be discussed only between the treating physician and a physician representing the third party carrier.

(5)  After thorough review of all submitted medical information, if the insurer’s physician disagrees with the certification request, be it the rule that the patient’s physician be allowed a consultation with the insurer’s consulting physician prior to any adverse decision.  The attending physician should be given the opportunity to provide additional medical information to substantiate the request for hospital admission.  If the patient’s physician disagrees with the initial consultation, be it the rule that a request for a second consultation be granted by the health insurer.  (Under these circumstances, further monetary penalties, i.e., reduced benefits, should not be imposed on the insured because of physician’s request for a second consultant.)  However, it is understood that reduced benefits may be imposed by the insurer if the patient does not adhere to the preadmission certification requirement to obtain a second opinion.

(6)  Physician-to-physician contact be the rule when there is disagreement between a treating physician’s plan of treatment and insurance company guidelines.  If there is a change of treatment plan, the insurer must give the treating physician ample time to notify his/her patient of such change.  Further, where disagreement exists between the physician and the insurer as to anticipated length of stays and preadmission certification, ample time must be allowed for the attending physician to apprise the patient that his/her contract may or may not provide full benefits for the prescribed plan of treatment, and any ensuing costs for the services provided may become the patient’s responsibility.

(7)  Since patients who inadvertently do not request required pre-admission and length of stay certification for services performed may be subject to reduced benefit payments, they must have right of appeal.

(8)  When emergency hospitalization is required, up to 48 hours (i.e., two business days, following the patient’s admission) must be allowed for the purpose of certification.

(9)  Health insurers must also be responsive to the desires of the State and local medical community concerning input into the establishment of criteria for preadmission certification programs.

(10)  In view of the significant increase in New York State health insurance plans requiring Preadmission Certification Programs, salient features of these programs, such as second surgical opinions, concurrent length of stays, and confirmation of emergency admissions, be implemented uniformly in order to mitigate confusion among the patient and physician community in such a way as to conform to the basic principles outlined in the foregoing Guidelines.  (HOD 1986-11; Amended Council 2/12/87; Amended HOD 3/14/87; Reaffirmed HOD 2013)

150.996           Professional Misconduct, Notification by Hospital to Accused

Physician

Any committee of a hospital that is duly constituted by the hospital to review matters involving professional misconduct should provide a physician who is accused of misconduct with notice of the charges, an opportunity to be heard, and any other safeguards that may be provided by the Bylaws.  The committee is required to report to the Board for Professional Medical Conduct only if it has information which reasonably shows that the physician is guilty of professional misconduct as defined by section 6530 of the Education Law.  (Joint Position of MSSNY and HANYS approved by Council 11/14/85; Reaffirmed HOD 2013)

150.997           Admitting Privileges

MSSNY supports the policy that hospitals should continue to offer equal hospital admitting privileges and equal access to beds to qualified physicians on their staff regardless of the physician’s choice of reimbursement mechanisms or their financial arrangements with their hospital.  (HOD 1982-58; Reaffirmed HOD 2013)

150.998           Attending Physicians and Residents, Guidelines For:

MSSNY adopted the following statement as part of its official position. It is a supplement to the Guidelines for Attending Physicians and Residents Established by the New York Academy of Medicine.  Because optimum care of hospitalized patients often entails technically sophisticated treatment modalities, reliance on the expertise of specialists and consultants, and frequent clinical assessments and judgments by house officers or other designees of the attending physician, it is imperative to specifically indicate the authority and responsibility for decisions about treatment and management.  Ethically and legally, the patient’s freely selected attending physician possesses this authority and responsibility.  Such action will strengthen the patient-physician relationship essential to the continuity of a patient’s care.  The patient’s own physician clearly retains ultimate responsibility for patient management but close cooperation between his/her own physician and the involved house officers and specialist consultants is essential to provide the highest quality of patient care.  Features of this cooperation should include at least the following:

(1)  Ongoing discussions and review of the patient’s course by the attending and other involved physicians.

(2)  Explicit approval and/or supervision by the amending of invasive, hazardous, or complex diagnostic or treatment procedures.

(3)  Explicit approval by the attending physician of the indications or requests for consultations, and of the choice of consultant.

(4)  Recognition by the attending physician to contribute to the education, training and learning experience of the house staff.

(5)  Conscientious efforts by the house staff and other involved physicians prompted to inform the attending physician of unexpected changes in the patient’s condition or needs for treatment.

(6)  Although there is recognition by both attendees and house officers that they share responsibility for writing orders, recording observations, or formulating analyses or treatment goals in the progress notes, the ultimate authority for patient care is the patient’s attending physician.*

These guidelines will best serve the goal of optimum care for the patient and will enhance the quality training for young physicians.  The attending physicians, hospital administrations, and house officers have the obligation to respect these guidelines and the attending physician shall candidly inform the patient of the roles of the various physicians in that patient’s care.  In such explanations, the patient’s right freely to select his/her own physician must be maintained.  No assignment of attending physician shall be made without prior discussion of available options with the patient and then only with his/her full knowledge and freely given consent.  (HOD 1982-51; Reaffirmed HOD 2013)

The Guidelines of the New York Academy of Medicine are available, upon request, at the Society Headquarters in Westbury.

NB:        Per General Counsel, this position statement was cited in the dissenting opinion in Somoza v. St. Vincent’s Hospital 596 N.Y.S. 2d 789 (App. Div., 1st Dept., April 22, 1993).  The majority decision nevertheless held that a hospital and a hospital resident may be held legally responsible where the hospital resident carries out the order of a private attending physician but knows, or should know, that the physician’s orders “are so clearly contraindicated by normal practice that ordinary prudence require inquiry into correctness of the order.”  The ruling, according to the majority decision, is an exception to the general rule followed by the courts which holds that the hospital and the hospital staff cannot be held legally responsible for the actions of a private attending physician as long as the hospital staff properly carries out the attending physician’s orders.

150.999           Medical Staff Criteria

The policy of the Medical Society of the State of New York is that admission to a hospital medical staff should be on an individual basis, after an impartial review of the applicant’s qualifications by the medical staff credentialing committee.  Such impartial review should serve as the basis for the hospital Board of Trustees’ final determination upon request for appointment to the medical staff, and that membership in any group affiliated with the hospital shall be a substitute for review of the individual’s qualifications.  (HOD 1980-25; Amended Council 1/22/81; Reaffirmed HOD 2013)

155.000          INDEPENDENT PRACTICE OF MEDICINE: 

 

155.996           Unionization of Independent Physicians

The Medical Society of the State of New York (MSSNY) with legal counsel will explore the following:

-the legal ability to and cost associated with physicians unionizing, under the legal theory that physicians have de facto become part-time employees of insurance companies;

-whether any established unions that represent employed physicians will support efforts to unionize physicians in independent practice;

-ways to enhance integration of independently practicing physicians through all legal means including IPAs and ACOs in order to enhance their leverage in negotiations with managed care plans and health insurers;

The Medical Society of the State of New York will initiate its exploration of the legal ability and cost associated with unionizing physicians in independent practice, whether any unions will support efforts to unionize physicians in independent practice and enhance integration of independently practicing physicians before the 2017 meeting of the MSSNY House of Delegates.  (HOD 2016-103)

155.997        Survival of Independent Practice

The Medical Society of the State of New York will set up a task force to explore all legally permissible options for independent physicians to collaborate and create practice models to achieve the goals of diversity of service, economy of scale, and collective negotiations.

This task force will consult with all necessary parties and examine models that have been used in other states in order to obtain the information necessary to conduct its assigned task; and the task force will report its findings to the Council of the Medical Society of the State of New York within six months of the ending of the 2015 meeting of the House of Delegates. The Council of the Medical Society of the State of New York will then develop a plan of action to preserve independent practice in New York State. (HOD 2015-210)

155.998           Support For “Concierge” Practices

The Medical Society of the State of New York supports the concept that a physician should be free to define a business model to practice medicine in New York that is most appropriate to that physician and his/her patients.  (HOD 2012-58)

155.999        Independent Practice of Medicine by Nurse Practitioners:

MSSNY, in the public interest, opposes the independent practice of medicine by any individuals who have not completed the presently prescribed education and the examination for licensure for the practice of medicine and, furthermore, has taken the position that the independent practice of medicine remain under the authority and control of the Board of Regents as assisted by the New York State Board for Medicine.  (HOD 1982-1; Reaffirmed HOD 2013)

157.000           INITIATIVES AND REFERENDUMS:

157.998           Tax Exemption for Feminine Hygiene Products

MSSNY will support legislation which removes the sales tax on feminine hygiene products.

The Medical Society of the State of New York will transmit a copy of this resolution to the AMA’s House of Delegates for its consideration.  (HOD 2016-168)

157.999        Initiative to Amend New York State Law to Allow Public Referendums and/or Ballot Propositions

MSSNY is to begin the process of developing a coalition of interested groups with the goal of amending New York State law to allow for Public Referendums, Initiatives, Recalls, Constitutional Conventions and/or Ballot Propositions.  (HOD 2011-119)

160.000          LICENSURE: (See also Managed Care, 165.000; Medicare, 195.000)

 

160.965           Tying Maintenance of Licensure to Maintenance of Certification

All physicians still in practice should be encouraged and enjoined to participate in activities to improve and maintain the knowledge and skills necessary to render the highest quality of care to his/her patients.  MSSNY strongly opposes any effort by the State of New York to require certification by any medical specialty board as a condition of obtaining or renewing the registration of a medical license in the State of New York.  The MSSNY Division of Governmental Affairs will make our position PROACTIVELY known to all appropriate agencies.  (HOD 2016-216) 

160.966           Maintenance of Certification

The Medical Society of the State of New York takes a position and will lobby against any linkage of licensure to Maintenance of Certification. MSSNY will simultaneously advocate for a varied approach to ensure appropriate continuing education for physicians.  (HOD 2016-213)

160.966           Maintenance of Certification

The Medical Society of the State of New York takes a position and will lobby against any linkage of licensure to Maintenance of Certification. MSSNY will simultaneously advocate for a varied approach to ensure appropriate continuing education for physicians.  (HOD 2016-213)

160.967           Automatic Link to Updating Physician Profile at Time of Licensure Renewal

The Medical Society of the State of New York will request, through regulation and/or legislation if needed, that the New York State Education Department and the New York State Department of Health (DOH) create an automatic link from the online education licensure renewal site to the DOH physician profile site to enable a physician who is re-registering with the state to also update his/her physician profile in a seamless manner.  (HOD 2015-112) 

160.968           Retirement of a Physician Medical Licensure

The Medical Society of the State of New York will seek legislation which provides non-disciplinary retirement of a physician license so long as there are no pending disciplinary matters. (HOD 2014-103) 

160.969           Maintenance of Licensure (MOL)

The Medical Society State of New York (MSSNY) shall oppose any Maintenance of Licensure (MOL) initiative that creates barriers to practice, is administratively unfeasible, is inflexible with regard to how physicians practice (clinically or not), that does not protect physician privacy, and that is used to promote policy initiatives (rather than competence) such as participation in health plans, subscription to data exchanges, and specialty board certification, etc. 

MSSNY shall submit to the American Medical Association (AMA), at its annual meeting, a resolution seeking its opposition to any MOL initiative that creates barriers to practice, is administratively unfeasible, is inflexible with regard to how physicians practice (clinically or not), that does not protect physician privacy, and that is used to promote policy initiatives (rather than competence) such as participation in health plans, subscription to data exchanges, and specialty board certification and further urging that the AMA oppose the FSMB MOL program as a condition of licensure.  (HOD 2014-56) 

160.970:          Transparency and Accountability for Specialty Boards and MOC

MSSNY calls on the American Board of Medical Specialties (ABMS) and its component specialty boards to increase their transparency and accountability to the physician community, and asks them to publish detailed reports of revenues and expenses, including compensation to board members and senior staff; require all board members and senior staff to annually disclose any potential conflicts of interest, professional or financial, to the physician community; and publish evidence -based data in peer reviewed articles in support of each component of their maintenance of certification (MOC) processes. MSSNY will bring this resolution to the AMA HOD for consideration at its June 2013 annual meeting. (HOD 2013-169)

160.971:          Opposition to Maintenance of Licensure

MSSNY opposes any efforts by the New York State Education Department, Office of the Professions, to require the Federation of State Medical Boards (FSMB) maintenance of licensure (MOL) program as a condition of medical licensure.  (HOD 2013-166 and 167; Reaffirmed HOD 2014-56)

160.972:          Opposition to Mandatory Maintenance of Certification

MSSNY opposes mandating Maintenance of Certification (MOC) until such time as evidence-based research demonstrates MOC is linked to improved patient outcomes. MSSNY acknowledges that the certification requirements within the MOC process are costly, time intensive and result in significant disruptions to the availability of physicians for patient care, and acknowledges and affirms the professionalism of individual physicians to self-determine the best means and methods for maintenance of their knowledge and skills. MSSNY will communicate to the American Medical Association and American Board of Medical Specialties examples of disproportional fees, onerous time requirements and unnecessary fragmentation of commonly recognized specialties, and will bring a copy of this resolution to the AMA House of Delegates for its consideration.  (HOD 2013-165 and 168)

160.973:          Avoid Restrictions on Medical Licensure

MSSNY believes that the ability to practice to the full extent of NYS medical licensure should not be infringed based on enrollment and/or participation in any publicly funded or private health-insurance program, and that physician participation in the Excess Medical Liability Insurance Program should not be based upon participating in Medicare/Medicaid, the State Insurance Exchange, and/or any governmentally subsidized health insurance program. (HOD 2013-53; Reaffirmed HOD 2014-53)

160.974           Physicians Should Not Be Penalized For Non-Participation In Government Medicine

It is the policy of the Medical Society of the State of New York that medical licensure in New York State shall not require participation in Medicare, Medicaid, or any other governmentally sponsored health insurance program. (HOD 2012-60; Reaffirmed HOD 2014-53)

160.975        Accurate Reporting of State Medical License Registration Expiration Dates on the AMA
                       Physician Profile

MSSNY will work with the American Medical Association (AMA) to ensure that the AMA Physician Profile and AMA Masterfile include the actual date of expiration of medical licensure registrations so that the AMA Profile does not continue to routinely truncate by one month all of the registration expiration dates for physicians. (HOD 2011-214)

160.976           Promoting Physician Retention in New York State:

MSSNY will support the advancement of legislation to retain its trained, qualified physicians, regardless of their citizenship or green card status and will also transmit a resolution to the American Medical Association for assistance in expediting citizenship for qualified physicians. (HOD 2009-155)

160.977           Physician Registration Fee:

MSSNY will continue to work to assure that the physician registration fee is used to support only activities related to the Office of Professional Medical Conduct, the Committee for Physician Health and other activities related to the physician workforce.  (HOD 2009-110)

160.978           Laser Vision Correction – Health Care Facility:

MSSNY adopted as policy that laser vision facilities must comply with the corporate practice of medicine prohibition to ensure patient protection and safety and optimal medical care and that MSSNY is to seek legislation or regulation to effectuate this change.  (Council 1/25/09)

160.979           Physician Registration Fee

MSSNY will oppose any future increase to the biennial physician registration fee.  (HOD 2007-107)

160.980           Opposition to Non-Physicians Performing Laser and Intense Pulsed Light Source Skin
                          Enhancement Procedures
:

MSSNY vigorously opposes certification of non-physicians (including non-medical personnel) to perform laser and intense pulsed light source skin enhancement procedures.  (HOD 2001-95; Reaffirmed Council 11/13/03; Reaffirmed HOD 2013)

160.981           Development of Legislation Regarding Physical Therapists (PTs):

MSSNY will seek through legislation, regulation, or whatever means necessary, the adoption of the following amendment to the New York Education Law:

(1)        Needle electromyography is the practice of medicine and shall be performed and interpreted only by physicians licensed in the State of New York who are appropriate to perform and interpret such tests by virtue of specialty and training; and

(2)        Physical therapists shall be limited in the scope of electro-diagnostic practice to the role of technicians utilized to perform nerve conduction studies under the direct supervision of a licensed physician who is appropriate to perform or interpret such tests by virtue of specialty and training; and

(3)        Non-licensed individuals as defined by the NYS Department of Education may not perform needle electromyography under any circumstance, whether or not the individuals are supervised by a licensed provider of any type.

MSSNY will request that the State of New York Insurance Department and the State of New York Workers’ Compensation Board, as they relate to the care of individuals sustaining automobile and work related injuries, respectively, adopt these resolutions in whole into their prevailing and future statutes.  (Council 11/2/00; Reaffirmed HOD 2014)

160.982           Enforcing Licensing Statutes:

MSSNY will seek support of the appropriate regulatory bodies to enforce licensing statutes to ensure that HMOs do not permit non-physician practitioners to perform services beyond the scope of their licensure. (Council 3/13/00; Reaffirmed HOD 2014)

160.983           Licensure of Non-Physician Practitioners:

MSSNY will seek support of the appropriate regulatory bodies to enforce licensing statutes to ensure that HMOs do not permit non-physician practitioners to perform services beyond the scope of their licensure.  (Council 3/13/00; Reaffirmed Council 11/13/03; Reaffirmed HOD 2013)

160.984           Citizenship Requirement for Medical Licensure: SUNSET HOD 2014

160.985           Destruction of the Doctor-Patient Relationship and the Practice of Medicine by Insurers:

MSSNY will seek legislation to discourage activities by insurers and other third parties that weaken or destroy the doctor-patient relationship including, but not limited to, the profusion of telephone based evaluation and referral by non-physicians.

Where managed care plans and insurers utilize nurses for “on-call” triage purposes, such nurses shall be licensed in New York State and provide, establish and maintain appropriate medical documentation of their activities as well as timely follow-up documentation to the patient’s primary care physician regarding the nurse’s assessment and recommendation; and that where MCOs provide triage services they must assume the liability for adverse events which may ensue.  (HOD 1998-75; Reaffirmed HOD 2014)

160.986           New York State Licensure Requirements:  SUNSET HOD 2014

160.987           Statutory Authority for Licensure:

MSSNY supports the statutory transfer of authority for license restoration from the Education Department to the Board for Professional Medical Conduct.  (Council 2/6/97; Reaffirmed HOD 2014)

160.988           Licensure Restoration Process:

MSSNY supports the following recommendations of the Office of the Professions, New York State Education Department, to improve and streamline the license restoration process:   An in-depth license restoration application to be developed with the burden being placed on the physician to explain why he or she should have the license back.

The establishment of a minimum waiting period of three years between the time a physician’s license is revoked and the time that a physician may reapply for license restoration.  The minimum waiting period is currently one year.

A graduated application fee for restoration is to be set so the physician covers the administrative cost of the restoration.  There is currently no fee or charge.

The need for a personal appearance in every case is to be eliminated, but to permit the state board the option of calling for a personal appearance.  (Council 2/6/97; Reaffirmed HOD 2014)

160.989           Licensure Requirement for Providing Medical Advice Through Telemedicine:

MSSNY will urge the New York State Board of Medicine to require full New York State licensure for an individual providing medical advice through the technology of Telemedicine from in or out of state for patients under treatment in New York State.  Such medical advice requiring full licensure would entail the performance of an act that is part of a patient care service initiated in this state and affecting the diagnosis or treatment of the patient.  Excluded from this full licensure requirement would be traditional informal physician-to-physician consultations (“curbside consultations”) that are provided without expectation of compensation.  MSSNY will recommend further monitoring and study of the areas of Telemedicine encompassing confidentiality of patient information, professional liability, coding and reimbursement, and will seek the development of legislation and/or regulation requiring the full New York State licensure of Medical Directors and physicians employed by managed care systems or other health insurers in or out of state who make decisions which affect medical care.  (Council 10/24/96; Reaffirmed HOD 2014)

160.990           Laser Surgery:

MSSNY has adopted the position that laser treatments should be prohibited by those not licensed as MD, DO, DMD, DDS, DPM-trained and will include this as a priority item in its 1997 legislative program.  (HOD 1996-80; Reaffirmed HOD 2014)

160.991           Self-Incriminating Questions

MSSNY has urged the American Medical Association to proceed further and revise the second recommendation of its Board of Trustee’s Report 13 (I-93) to urge that questions as in current illnesses that might interfere with the competency to practice be applied to all such illnesses, physical as well as psychiatric and addictive, and not to the past history of such illnesses if those illnesses do not extend into current impairment, and to amend its Board of Trustee’s Report 13 (I-93) so that it applies to all licensing, board certifying, and credentialing procedures.  MSSNY has urged the AMA to add to its Board of Trustee’s Report 13 (I-93) a strong emphasis on the need for very strict confidentiality legislation and regulations on state, federal and private levels in regard to any such information obtained, and to implement recommendations 4 and 5 of said report relating to the impact of the Americans with Disability Act (ADA) concerning these matters.  (HOD 1994-161; Reaffirmed HOD 2014)

160.992           Mandated CME for Re-registration of Medical Licensure

The Society strongly reaffirmed its opposition to any linkage between legislatively mandated CME with re-registration of medical licenses.  (HOD 1993-15; Reaffirmed HOD 2014)

160.993           Self-Incriminating Questions on Application Forms by Licensing, Certifying and
                         Credentialing Bodies

MSSNY takes the position that questions regarding past history of referral and treatment for alcohol and other drug disorders and mental and emotional illness should not be used on application forms by licensing, certifying, and credentialing bodies because it is not believed that such questions are pertinent to a physician’s current ability to practice medicine but merely infringe on privacy matters. MSSNY is urging that such bodies instead ask a question regarding the applicant’s current ability to practice medicine, such as: “Is your ability to practice medicine currently impaired by any physical, mental, emotional, alcohol or substance abuse disorder?”  (Council 7/23/92; Reaffirmed HOD 2014)

160.994           Therapeutic Ultrasound

It is the position of the Medical Society of the State of New York that therapeutic ultrasound be performed only by individuals licensed to practice medicine and surgery or by those who have been specifically authorized by law to perform these services.  (HOD 1991-47; Reaffirmed HOD 2014)

160.995           Cryotherapy:

It is the position of the Medical Society of the State of New York that cryotherapy be performed only by individuals licensed to practice medicine and surgery or by those who have been specifically authorized by law to perform these services.  (HOD 1991-46; Reaffirmed HOD 2014)

160.996           Diathermy

It is the position of the Medical Society of the State of New York that diathermy be performed only by individuals licensed to practice medicine and surgery or by those who have been specifically authorized by law to perform these services.  (HOD 1991-48; Reaffirmed HOD 2014)

160.997           Single National Examination for Medical LicensureSUNSET HOD 2013

160.998           Licensure Based on Professional Standards

It is the position of the Medical Society of the State of New York that physician licensure be based solely upon professional standards, including training, education, ability, competence and moral fitness.  The Society vigorously opposes any attempts to establish nonprofessional standards, such as acceptance of third-party payment, as a condition of medical licensure.  (HOD 1989-6 ; Reaffirmed HOD 2013)

160.999           Licensure as a Prerequisite for Membership in the Medical Society of the State of New
                         York
:

At the present time there is no official State Society policy as to the requirement of licensure as prerequisite for membership. (Council 12/16/76; Modified and reaffirmed HOD 2013)

165.000      MANAGED CARE:

                  (See also Health Care Delivery Systems, 110.000; Health System Reform, 130.000; Health Information Technology, 117.000; Licensure, 160.000; Medicare, 195.000; Reimbursement, 265.000; Rights and Responsibilities of Physicians, 270.000; Utilization Review, 310.000; Workers’ Compensation, 325.000)

165.844           Medicare Advantage Plans Seeking Chronic Condition/Diagnosis Data

The Medical Society of the State of New York will urge the Centers for Medicare and Medicaid Services (CMS) to develop formal guidelines for chart requests that Medicare Advantage (MA) plans issue in anticipation of CMS “risk–adjustment/diagnosis data reviews” (reviews in which CMS investigates patients’ health status, with the intent of paying the MA plan more for patients with multiple chronic conditions than for patients with single conditions).  These chart request guidelines for Medicare Advantage (MA) plans should set limits on (1) the number of medical records that the MA plan is permitted to list in a single request of this type, and (2) the number of separate requests that the plan is permitted to issue to a physician practice within a given time period.  MSSNY will urge the Centers for Medicare and Medicaid Services (CMS) to distribute those guidelines to their contracted Medicare Advantage plans (MA) plans, and require the plans to comply with them.  (HOD 2015-255) 

165.845           Lombardi Program “Nursing Home without Walls”

The Medical Society of the State of New York will work to ensure the continuity of the Long Term Home Health Care Program (LTHHCP) in managed care contracts and with the AMA will work to ensure that the federal waiver authority which authorized the Long Term Home Health Care Program (LTHHCP) does not expire in September of 2015.

MSSNY will urge the New York State Department of Health to conduct a study to evaluate the clinical and cost effectiveness of the Long Term Care Health Care Program (LTHHCP) as opposed to Medicaid Long Term Care to determine the efficacy of one or both models in the evolving health care system.  (HOD 2015-108) 

165.846           Provider Representative Accessibility

The Medical Society of the State of New York will work with the New York State Department of Financial Services to ensure health insurance companies have sufficient staffing to expeditiously respond to questions from physicians and their staff regarding their patient’s coverage, and that insurers will face financial penalties for failing to ensure such availability.

The Medical Society of the State of New York will seek legislation to assure that if an insurer fails to respond to a physician request for pre-authorization of patient care within one day of such request, then that care should be covered.  (HOD 2015-68) 

165.847           Pharmacy Benefit Managers Interfering with the Progress and Continuity of Treatment

The Medical Society of the State of New York will advocate to ensure that patients stabilized on a particular medication regimen are not forced to change such regimen based upon a change in formulary or insurance coverage change; and that insurers provide continuous coverage for patients for medications previously approved.

The Medical Society of the State of New York will seek legislation or other means to ensure health insurance companies provide coverage without need for prior approval for medications needed on an urgent basis, for example, Suboxone for a symptomatic patient in acute opioid withdrawal.

The Medical Society of the State of New York will continue to advocate that contractors of health insurance companies, such as Pharmacy Benefit Managers, are subject to the same utilization review rules that health insurers are required to follow. (HOD 2015-57) 

165.848           Medicare Advantage Insurer Abuses

The Medical Society of the State of New York will ask the Attorney General to review the practice of managed care plans requesting medical records which are not for quality or utilization review but for business/reimbursement enhancement and that the Attorney General review situations whereby managed care plans, under the guise of doing a health assessment, have personnel visit an insured at home for a medical exam and discussion of the insured’s medical history.  MSSNY will urge the Attorney General to ensure that managed care plans which conduct these home “assessment” visits for the purpose of garnering added funds from the plans’ overall administrator (ie, the employer, county state, CMS, etc.) be certain that the plans insureds/patients have a clear understanding of who is coming into their home and the purpose for the examination and history being conducted by the managed care plan’s staff and further that managed care plans obtain clear and explicit consent from patients for these visits. (HOD 2013-252; referred, amended, adopted Council 4/13/2014)

165.849:          Lack of Transparency in Insurers’ Final Audit Findings

MSSNY should draft legislative proposals regarding third–party insurers’ medical records audits, or work to amend existing proposals, to require that when a final audit finding is accompanied by a refund demand, the insurer must at least state: (a) the identity and medical qualifications of the insurer reviewer; (b) the standards of medical practice and medical record documentation that the reviewer used; (c) the source(s) of any utilization statistics or peer group activities cited; (d) a detailed, patient–by–patient analysis of the alleged insufficiencies in the documentation, including alleged insufficiencies in the documentation of history, exam, and medical decision making; and (e) the full text of the insurer’s most recent in-house policy regarding each service under review. (HOD 2013-258; reaffirms Policies 165.861 and 165.992)

165.850:          Insurers’ Use of Offsets with Refund Demands

MSSNY will collect examples from physicians of health plans’ attempts to collect alleged overpayments by inappropriately offsetting other payments owed when a physician challenges the alleged overpayments; will present these examples of offsets to the State Department of Financial Services to determine whether these offsets violate Section 3224-b of the Insurance Law; and will continue to seek legislation or regulation that prohibits an insurance company from offsetting payments owed to physicians to pay back alleged overpayments unless the physician executes a clearly stated consent separate from the participation contract. (HOD 2013-58)

165.851           Barring Restrictive Covenants

The Medical Society of the State of New York will advocate for legislation to limit restrictive covenants contained within physician employment contracts between hospitals and a physician to employment with other article twenty-eight entities and reaffirms policy 165.856.  (HOD 2012-101)

165.852           Payment for Pre-Authorized Services

The Medical Society of the State of New York will seek legislation, regulation, or other appropriate means which requires health insurance companies to certify a patient’s eligibility prior to authorizing the performance of medically necessary services, and once an insurance company has provided such prior authorization and certification, that the authorization is irrevocable for 30 days from the date of the authorization, and the insurer may not seek a refund from the physician after performance of the services due to patient’s lack of coverage at the time of service. (HOD 2012-56)

165.853           Protecting New York State Physicians with Multiple Tax ID Numbers

The Medical Society of the State of New York will seek legislation and/or regulation which prevents managed care organizations from requiring physicians to participate under all of their tax ID numbers if they participate under one tax ID number. 

The MSSNY Delegation to the American Medical Association (AMA) will bring this resolution forward to the AMA House of Delegates.  (HOD 2012-258) 

165.854           Fair and Free Access to Data from Multiple RHIOs

The Medical Society of the State of New York (MSSNY) will work with the New York eHealth Collaborative (NYeC) and the New York State Department of Health (DOH) to ensure that any physician who subscribes to one RHIO be given the option of participating in any other RHIO’s for no additional fees, whether from the RHIO’s themselves or from EMR portals.

MSSNY will also request that the NYeC and the DOH negotiate for cross-subscription agreements with the RHIOs of neighboring states and advocate for similar agreements within the Nationwide Health Information Network so that patients near the borders of New York also have fair access to the advantages of RHIOs.

MSSNY will make a request to the Health Commissioner to implement regulations that would fund RHIO connections through EMRs without fees to providers for participation. (HOD 2012-103)

165.855           Identification of Insurance Plans by Payer ID:

MSSNY will:

  1. Urge the NYS Insurance Department to formulate regulations to require greater clarity from NYS health plans with respect to patients’ health insurance cards for identification of the payer’s claim address, product line (Medicare, Medicaid, PPO, HMO, etc.), primary care physician, co-payment(s), deductible, and/or co-insurance amounts, etc.;
  2. Seek to have patients’ health plan cards identify the health plan’s website and direct link to the webpage access for verifying patient eligibility and financial responsibility (i.e. co-payment(s), deductible, co-insurance, etc.);
  3. Seek the development of swipe-card technology in real-time (24/7) with verification.
  4. Urge the NYS Insurance Department to formulate regulations to require greater clarity from NYS health plans with respect to patients’ health insurance cards for identification of the payer’s claim address, product line (Medicare, Medicaid, PPO, HMO, etc.), primary care physician, co-payment(s), deductible, and/or co-insurance amounts, etc.;
  5. Seek to have patients’ health plan cards identify the health plan’s website and direct link to the webpage access for verifying patient eligibility and financial responsibility (i.e. co-payment(s), deductible, co-insurance, etc.);
  6. Seek the development of swipe-card technology in real-time (24/7) with verification. (HOD 2011-250; Reaffirmed HOD 2016-256)

165.856           Restrictive Covenants in Physician Employment Contracts

MSSNY policy regarding restrictive covenants is that they are unethical if they are excessive in geographic scope or duration in the circumstances presented, or if they fail to make reasonable accommodation of patients’ choice of physician.  (HOD 2011-112; Reaffirmed Council 11/29/2012)

The Medical Society of the State of New York should advocate for legislation to limit restrictive covenants contained within physician employment contracts between hospitals and a physician to employment with other article twenty-eight entities. (HOD 2012-101; referred to, modified by and adopted by Council 2011-2012) 

165.857           Expert Medical Advice by Insurance Companies:

MSSNY to take all appropriate steps necessary to prevent health insurance companies from advertising and providing medical treatment advice to patients when the patient has not received an in-person examination or appropriate medical evaluation.  (HOD 2011-62)

165.858           Options for Physicians When an Insurance Plan Becomes Insolvent:

MSSNY will (1) seek legislation or regulation that would permit physicians to bill plan subscribers if their insurer became insolvent; and (2) advocate to the State Insurance and Health Departments to assure that health insurance companies remain adequately capitalized to pay patients’ health insurance claims.  (HOD 2011-61)

165.859           Deductible Transparency

MSSNY will seek (a) legislation, regulation or other appropriate means to require health insurance companies to provide a patient’s in-network and out-of-network deductible information both on the patient’s insurance card, as well as be available on the health insurance company’s website; and (b) assurance that the deductible information provided on the company’s web site be updated immediately when an insured’s deductible and/or policy has changed. (HOD 2011-60; Reaffirmed HOD 2016-256)

165.860           Provider Agreements

MSSNY will seek legislation or other appropriate means to prohibit provisions in physician contracts with health insurers that automatically renew the contract at the end of the term.  (HOD 2011-57)

165.861           Violations of State Insurance Laws by Managed Care Organizations and Private Insurers

MSSNY will take the following action:

  1. Seek legislation or other appropriate means to a) prohibit health insurance companies from demanding refunds from physicians without providing physicians a detailed audit report which clearly identifies the claims in question and the methodology utilized to arrive at the alleged overpayment amount; b) eliminate or establish a more objective definition of the “abusive billing” exception to the two year current statutory limitation on health plan overpayment recoveries c) permit physicians a meaningful opportunity to appeal a requested refund demand including review by an independent body and d) prohibit automatic offset provisions in physician contracts;
  2. Work to assure that the New York State Insurance Department and Attorney General’s office appropriately investigate and resolve complaints made by physicians regarding violations of the New York State Insurance Law by health plans, including violations of: the Prompt Payment law; laws that limit refund demands and recoveries; and laws which specify a minimum period of time to submit claims;
  3. Educate and encourage physicians to submit suspected violations of these laws to the New York State Insurance Department and Attorney General. (HOD 2011-55; Reaffirmed HOD 2013-258 and 2013-57)

165.862           Clarification of Chapter 551 Law – Insurance Law Sections 3224-b and 4803(a):

MSSNY will:

  1. Initiate a legal review of the provision of the Chapter 551 Law (Insurance Law Sections 3224-b and 4803(a)) that states that “all accident and health insurers and Article 43 corporations (“insurers”) and health maintenance organizations are required to accept and initiate the processing of physicians’ claims utilizing the American Medical Association’s (AMA’s) current procedural terminology (CPT) codes, reporting guidelines and conventions and the Centers for Medicare & Medicaid Services (CMS) Health Care Common Procedure Coding system (HCPCS)”;
  2. Review (1) whether that section of the law specifically requires insurers to use the AMA CPT coding manual (particularly that manual’s Introductory Section and its narrative policy sections), and (2) whether the law also requires insurers to use all other standard coding conventions as well;
  3. Seek legislation and/or regulatory relief, in regard to the provision in the Chapter 551 Law (Insurance Law Sections 3224-b and 4803(a)) that contains the phrase “codes, reporting guidelines and conventions,” mandating that insurers incorporate all AMA CPT guidelines and conventions, as well as codes, in their payment policies. (HOD 2011-54)

165.863           American Well:

MSSNY will:

(a) continue to advocate for compensation of care provided by physicians to their patients via electronic means;

(b) work with the NYS Education Department, the NYS Department of Health and the Office of Professional Medical Conduct to assure that only NYS-licensed physicians provide care to patients in NYS;

(c) work to ensure that the product offered by American Well follows all pertinent laws for New York State relative to its business and that any liability insurance offered by American Well is licensed in New York State.

In addition, all physicians who choose to participate in the provision of online care shall be entitled to participate in all such programs.  (HOD 2010-267)

165.864           Pre-Authorized Services by Non-Participating Physicians:

MSSNY will seek legislation/regulation mandating that when an out-of-network physician has obtained prior authorization (verbal or written) to perform medically necessary services/procedures, that insurance companies be precluded from utilizing communications (i.e., letters, EOBs, etc.) which contain language urging/directing patients to obtain the requested services from an in-network provider with the threat of being exposed to the imposition of additional out-of-pocket expenses due to their continued use of out-of-network physicians.  (HOD 2010-266) 

165.865           Support Community Rating for Health Insurance:

MSSNY adopted as policy the existing AMA Policy H-165.856, “Health Insurance Market Regulation”:

Health Insurance Market Regulation

Our AMA supports the following principles for health insurance market regulation:

(1) There should be greater national uniformity of market regulation across health insurance markets, regardless of type of sub-market (e.g., large group, small group, individual), geographic location, or type of health plan;

(2) State variation in market regulation is permissible so long as states demonstrate that departures from national regulations would not drive up the number of uninsured, and so long as variations do not unduly hamper the development of multi-state group purchasing alliances, or create adverse selection;

(3) Risk-related subsidies such as subsidies for high-risk pools, reinsurance, and risk adjustment should be financed through general tax revenues rather than through strict community rating or premium surcharges;

(4) Strict community rating should be replaced with modified community rating, risk bands, or risk corridors. Although some degree of age rating is acceptable, an individual’s genetic information should not be used to determine his or her premium;

(5) Insured individuals should be protected by guaranteed renewability;

(6) Guaranteed renewability regulations and multi-year contracts may include provisions allowing insurers to single out individuals for rate changes or other incentives related to changes in controllable lifestyle choices;

(7) Guaranteed issue regulations should be rescinded;

(8) Health insurance coverage of pre-existing conditions with guaranteed issue within the context of an individual mandate, in addition to guaranteed renewability.

(9) Insured individuals wishing to switch plans should be subject to a lesser degree of risk rating and pre-existing conditions limitations than individuals who are newly seeking coverage; and

(10) The regulatory environment should enable rather than impede private market innovation in product development and purchasing arrangements. Specifically:

(a) Legislative and regulatory barriers to the formation and operation of group purchasing alliances should, in general, be removed; (b) Benefit mandates should be minimized to allow markets to determine benefit packages and permit a wide choice of coverage options; and (c) Any legislative and regulatory barriers to the development of multi-year insurance contracts should be identified and removed. (CMS Rep. 7, A-03; Reaffirmed: CMS Rep. 6, A-05; Reaffirmation A-07; Reaffirmed: CMS Rep. 2, I-07; Reaffirmed: BOT Rep. 7, A-09; Res. 129, A-09)    (MSSNY HOD 2010-263)

165.866           Online Access to Managed Care Organizations’ Professional Relations Department

MSSNY will:

draft a legislative proposal requiring New York State private insurers and managed care organizations to provide physicians with access to their Professional or Provider Relations staff, so that the physicians can request assistance from these representatives;

recommend that, in order to accommodate participating physicians’ questions and requests for assistance, the private insurers and managed care organizations augment their present Internet and e-mail capabilities by (1) placing their Professional/Provider Relations representatives’ contact information on-line, and/or (2) providing lists of representatives’ territories by zip code, including the phone, fax, and e-mail address of the Professional / Provider Relations representative responsible for each zip code;

recommend punitive measures, applicable to the insurers themselves, that would apply if an insurer’s Professional/Provider Relations staff fails to respond in a timely manner to a participating physician’s question or request for assistance; such punitive measures might include fines, performance reviews and/or a requirement that the insurer pay the claim.  (HOD 2010-255; Reaffirmed HOD 2015-68)

165.867           Timely Discussion Between Treating Physician and the Insurance                         Company’s Medical Director When Services are Denied Based on Medical Necessity:

MSSNY will seek legislation and/or regulation to assure that the Insurance Company’s Medical Director be directly available, within 2 business days, to discuss a denial based on medical necessity with the treating physician.  (HOD 2010-252)

165.868           United Healthcare/Oxford Subscriber Identification Cards

MSSNY will urge the Superintendent of Insurance, and any other pertinent official or governmental agency to require United Healthcare/Oxford to issue identification cards to its subscribers which prominently identifies the primary insurance company name (either United Healthcare or Oxford) with the appropriate mailing address, so as to avoid any confusion as to which insurance company is actually responsible for payment.  In the event that a claim is denied for timely filing because of the obfuscation of United Healthcare in clearly identifying the appropriate entity responsible for payment, United Healthcare should be required to make restitution to the physician for the denied claim.  (HOD 2010-251)

165.869           Participating Provider Lists:

MSSNY will request that the State Superintendent of Insurance and the State Legislature (1) establish criteria for insurers to review and update participating provider lists on a regular basis and

(2) establish penalties for substantial inaccuracies in provider lists.  (HOD 2010-59)

165.870           Minimum Medical Loss Ratio

MSSNY will support legislation that would

(1) require health insurers to spend a minimum of 85% of their collected premiums on medical care as a means of ensuring that insurance companies become more efficient while making health care more affordable and

(2) if a health insurance company fails to maintain an 85% medical loss ratio, any excess be refunded to the premium payers.  (HOD 2010-55)

165.871           Healthcare Reform

MSSNY will continue to advocate for the end of abusive managed care practices that threaten the viability of physician practices and patient access to care.  (HOD 2010-54)

165.872           Insurance Industry Antitrust Protection:

MSSNY will support repeal of antitrust exemptions afforded to health insurance companies under federal law that may permit health insurance companies excessive domination and anti-competitive control over physicians in any given market.  (HOD 2010-53)

165.873           Discriminatory Treatment of Psychiatrists’ Use of E/M Codes:

MSSNY will call upon the New York State Department of Insurance and the New York State Department of Health to enforce New York Insurance Law §3224-b (Chapter 551 of the Laws of 2006) and to inform all health plans in writing that the provisions of New York Insurance Law §3224-b mandate that:

  1. if a health plan covers (i.e., accepts, processes and provides reimbursement for) Evaluation and Management (E/M) services provided by physicians in their office or in the hospital, then health plans must accept, process and reimburse claims submitted by psychiatrists for E/M services in the same manner and to the same extent as provided for E/M services provided by physicians in other specialties (subject to any limitations on coverage of the treatment of mental illness under the health plan and permitted by law);
  1. to the extent that a health plan provides coverage for specific E/M codes, health plans must accept and process claims for those E/M codes submitted by physicians without limitation or restriction based upon the physician’s medical specialty;
  1. health plans cannot restrict psychiatrists to submitting claims only for psychiatry procedure codes and must permit psychiatrists as well as all other physicians to use all E/M codes covered under the health plan. (HOD 2009-263)

165.874           Collaborative Efforts with the Bar Association:

MSSNY will:

  1. support collaborative efforts with the bar association to remove the Employee Retirement Income Security Act of 1974 (‘ERISA’) shield that pre-empts action against health plans for the adverse outcomes that result from their delays or their medical decision making;
  1. ask the American Medical Association (AMA) to support collaborative efforts with the bar association to remove the ‘ERISA’ shield that pre-empts action against health plans for the adverse outcomes that result from their delays or their medical decision making; and,
  1. together with the AMA, utilize this collaboration and the American Bar Association (ABA) policy that supports alternative dispute resolution (ADR) mechanisms to facilitate movement toward medical liability reform. (HOD 2009-69)

165.875           Condemnation and Reporting of Unilateral Physician Fee Reduction by Any Health Plan:

MSSNY will

(1) condemn the unilateral reduction of fees paid to participating physicians by any health plan;

(2) present this issue promptly to the Governor of the State of New York, the Majority and Minority Leaders of the State Senate, the Speaker and Minority Leader of the State Assembly and the Superintendent of Insurance; and

(3) have the New York Delegation to the American Medical Association bring this issue to the AMA’s next Annual Meeting for action on the federal level.  (HOD 2009-67)

165.876           Ownership of Managed Care Organizations:

MSSNY will advocate for legislation or regulation that would prohibit a health insurance company from having a financial interest in any subsidiary or other organization which may negatively influence health care spending, such as restrictions on patient access to care or reductions in physician reimbursement.  (HOD 2009-61) 

165.877           Increase Medical Loss Ratios:

MSSNY will seek legislation or regulation requiring

(1) health insurers to increase their medical loss ratios as well as mandating that they meet a minimum medical loss ratio; and

(2) increased transparency of health insurers’ premium dollars, that they publicly disclose information on their medical loss ratios in an easily understandable manner, including allocations for salaries and administrative costs.

Also, MSSNY should collect, collate, compare and publish up-to-date data on health insurers doing business in New York State.  (HOD 2009-60)

165.878           Insurance Company Merger:

MSSNY will (a) support the conversion of Emblem to a not-for-profit mutual company governed by and accountable to those it insures; and (b) reaffirm the Society’s vehement opposition to Emblem’s for-profit conversion.  (HOD 2009-56)

165.879           Medical Smart Cards

  1. MSSNY will educate its members through News of New York, the MSSNY website and other appropriate means of communication, regarding the benefits, technology and availability of medical smart cards, and keep members informed of developments and opportunities in this emerging technology.
  1. MSSNY will communicate with health care organizations and health insurance plans throughout New York State to urge the development and use of medical smart cards for the purposes of:
  1. making patients’ information readily available;
  2. simplifying the task of eligibility verification in physician offices, and
  3. enhancing and ensuring HIPAA compliance with conversion of paper-based health care information to electronic systems that guarantee the privacy and security of patient information gathered as part of providing health care.
  1. MSSNY will work with health care insurers and agencies to ensure that physicians do not incur any added expenses to incorporate the use of a health insurer’s / agency’s generated medical smart card into their practice. In addition MSSNY urge those entities, including vendors, which currently charge physicians a fee for smart card readers to provide these free or at a steep discount for MSSNY members.
  1. MSSNY will develop a collaborative working relationship with the HANYS’ newly created Office of Health Information Technology Transformation, which is studying the development of sustainable health information exchanges on community, regional, and state levels (Regional Health information Organizations or RHIOs). In addition, MSSNY strive to become an active participant in the GNYHA newly created New York Clinical Information Exchange (NYCLIX) whose goal is to “increase patient safety and the efficiency of care by creating a virtual network for sharing of patient data among health care entities for the purpose of treatment.” NYCLIX is now embarking on the planning phase in order to create implementation of patient data sharing. Both of these initiatives (HANYS and GNYHA) are unique opportunities for MSSNY to provide physician input and expertise at the early stages of these projects.
  1. MSSNY’s AMA Delegation will prepare a Resolution to be forwarded to the AMA House of Delegates to study and develop a “white paper” on the issue of medical smart cards, including the role of organized medicine and specific implications for physicians, patients and healthcare, in general. (Council 1/25/09)

165.890           Guidelines for Executive Compensation in Health Insurance Companies:

MSSNY will urge the enactment of federal legislation or regulation that will establish guidelines for executive compensation in health insurance companies that assures appropriate and responsible allocation of resources for health care delivery. (HOD 2008-67)

165.891           Patient-Directed Educational Campaign Regarding Managed Care

Organizations:

As part of its ongoing efforts to achieve meaningful reform of abusive managed care practices, MSSNY will (a) utilize educational materials that encourage physician and patient grassroots advocacy; and (b) work to educate physicians, the public and patients regarding the increasing threat to the health care delivery system caused by excessive health plan market share, profits and executive compensation.  (HOD 2008-64)

165.892           Contract and Fee Schedule Disclosure:

MSSNY to seek legislation, regulation or other appropriate means to compel health plans to provide physicians with full written contracts with all changes highlighted, a full fee schedule applicable to the physician’s specialty, and a written summary of such changes, each time they renew the contract.  (HOD 2008-59)

165.893           Changes in the Overpayment Recovery Law:

MSSNY will seek legislation, regulation or other appropriate means to:

  1. assure that meaningful fines and penalties are imposed on health plans that violate the current two-year statutory limitation on health plan refund demands as well as the requirement that health plans provide 30 days notice before initiating efforts to recover an alleged overpayment;
  2. limit the time that health plans can seek repayment of overpayments to physicians to the same time that a physician has to submit a claim;
  3. require that, in the event a physician has paid a recovery to a Managed Care Organization due to erroneously billing the MCO rather than the correct insurer (e.g. no-fault or Workers’ Compensation), the appropriate responsible party be required to honor a claim for the services rendered for a period of 60 days form the date of the recovery. (HOD 08-58; Reaffirmed HOD 2011-55)

MSSNY recommends that section 3224-B of the insurance law be amended to require health plans to initiate overpayment proceedings within 2 months (60 days) from the date the claim was paid and will continue to seek the enactment of legislation; regulatory or other means to prohibit using extrapolation to determine refund demand amounts in the absence of fraud or intentional misconduct.  (HOD 2013-55 and 56)

MSSNY will work to remove all references to fraud and/or abuse from the State’s refund demand “look back” law and also amend Assembly Bill A.1538 (on the state’s refund demand “look back” law) to (a) require that the law define “reasonable belief” and (b) require insurers to support their “fraud and abuse” allegations with detailed analyses of alleged deficiencies in the charts. MSSNY will also continue to seek legislation that would eliminate the “abusive billing” exception to the statutory look back limit. (HOD 2013-57)

165.894           Tracking Electronic Claims:

MSSNY will seek legislation or regulation mandating health payment plans that require electronic claims submission be required to make available the means of tracking the claim electronically as it is processed.         (HOD 2007-265)

165.895           Requirement for MCOs to Provide Education and Training Initiatives:

MSSNY will legislation that would require:  (1) each third-party insurer to develop and implement a formal Local Provider Education and Training (LPET) Initiative, designed to give panel physicians all the information they need now and in the future about the carrier’s policies, procedures, and coverage issues, in order to receive appropriate reimbursement; and (2) third-party insurers to provide dedicated and identifiable staff, telephone lines, and e-mail addresses, whereby physicians can contact the carrier in order to fully understand and abide by the carrier’s policies and procedures.  (HOD 2007-256)

165.896           Retraction Letters and Erroneous Termination Letters:

MSSNY will work with the appropriate New York State regulatory agency to draft regulations requiring managed care organizations (MCOs) to issue letters of retraction when the MCO has erroneously informed patients that a physician is no longer participating, when the physician has merely filed a request to change the demographic information in the plan’s Provider File.  (HOD 2007-254)

165.897           MCOs Use of Pre-Payment Claim Reviews to Circumvent the New York State Prompt Payment Law:

MSSNY will:

(1)        using the Hassle Factor Form, solicit and compile examples of prepayment claim reviews initiated by managed care organizations where the physician has received no prior notification of aberrant coding or claim submission practices;

(2)        review these examples to determine whether the managed care organizations are in violation of the New York State Prompt Payment Law or related regulatory directives, such as the New York State Insurance Department Regulation # 178 (11 NYCRR 217) (Prompt Payment of Health Insurance Claims) or Article 26 of the Unfair Claim Settlement Practices law (Section 2601); and

(3)        urge the New York State Insurance Department to take appropriate action against these managed care organizations if it is determined that the MCOs are indeed in violation of the relevant statutes or regulations through their use of erroneous pre-payment reviews.  (HOD 2007-253)

165.898           Health Care Reinvestment Fund:

MSSNY will support legislation to (1) create a health care reinvestment fund to assure that a portion of health insurer profits are returned to physicians and hospitals within the service area served by each insurer; and (2) limit an insurer’s medical loss ratio.  (HOD 2007-110)

165.899           Phlebotomy Services by Physician Offices:

MSSNY to oppose penalties on physicians for referring patients for out-of-network services and work with health insurance plans to appropriately reimburse the expense for phlebotomy services at physician offices.  (HOD 2007-73)

165.900           Bar For-Profit Health Plan Operations:

In addition to MSSNY’s seeking legislation to bar for-profit plan health insurance operations in New York State, it should also (1) publicize the better claims settlement and quality of care indicators of non-profit plans over for-profit plans; (2) take all steps necessary to assure that health insurers seeking to convert to for-profit status are required to rectify frequent complaints and address other patient and physician concerns as a condition of being permitted to convert to for-profit status; and (3) continue to seek legislation and regulation to rectify the abusive claims processing practices of all health plans. (HOD 2007-72; Reaffirmed HOD 2008-66; Reaffirmed HOD 2009-56; Reaffirmed HOD 2010-56)

165.901           Health Care Providers and Antitrust:

In acknowledging that federal antitrust agencies have consistently placed physicians under a far higher level of scrutiny than is warranted by their comparative economic strength in today’s health care system, MSSNY to pursue relaxation or exemption of antitrust laws as applies to physicians in order to promote greater connectivity, and thus improve health care outcomes and cost savings that will result from improved outcomes.  (HOD 2007-71; reaffirmed Council 11/20/08; Reaffirmed HOD 2009-56; Reaffirmed HOD 2010-53 & 54)

165.902           Insurance Product Oversight by the Superintendent of Insurance:

MSSNY will seek a change in legislation so that New York State reinstates the rate review authority of the Superintendent of Insurance and to press for legislative reinstatement of earlier regulations requiring insurance companies doing business in New York State to submit to the Commissioner of Insurance all proposed changes in products and premium rates for prior review and approval.  (HOD 2007-70; Reaffirmed HOD 2010-54)

165.903           Contract Termination – Merged MCOs:

MSSNY continues to support the ability of a physician to choose the health plans and the health plan products with which they will participate, and continues to oppose efforts by health plans to require physicians to participate with all affiliates of a particular plan or all products offered by a particular plan; and

Should health plans continue to have the ability to require physicians to participate in all its affiliates, MSSNY will advocate for legislation to assure that:

  1. a) newly merged health plans are required to follow the termination protocols of the health plan that provides more beneficial terms to the physician; and
  2. b) permits the physician wishing to terminate from the health plan and all its affiliates to execute such termination by contacting the plan with which the physician originally contracted. (HOD 2007-69; Reaffirmed HOD 2016-52)

165.904           Reform of Managed Care Denial Process

MSSNY will:

(1) support legislation or regulation requiring health plans to submit quarterly detailed schedules of reimbursement denials, including the number of denials, the amount, and the reasons for denials to deter abusive practices and improve quality of care;

(2) continue sharing with all relevant state agencies the most frequent causes of health plan denials reported to MSSNY, so that the Superintendent of Insurance and Commissioner of Health may investigate such denials; and

(3) urge the Superintendent of Insurance to investigate patterns of inappropriate denials by health plans as part of their routine market conduct audits. (HOD 2007-68)

165.905           Reimbursement for Pre-Authorized Services Subsequently Denied by

MCOs:

MSSNY will take all appropriate steps to assure that physicians have the ability to seek payment from patients where a health plan subsequently denies a pre-authorized service and seek to assure that the insurer notify the patient regarding their financial responsibility.  (HOD 2007-67)

165.906           Hard-Coded Personal Computer Dates as Proof of Timely Filing of

Paper Claims:

Legislation, regulation, or other appropriate means will be sought by MSSNY to require all insurers, including workers compensation carriers, to accept hard-coded-system generated data as proof that a paper claim was timely filed, provided the physician attests that the claim was mailed on or about the day the claim was generated.  (HOD 2007-65)

165.907           Clarification of the New York State Current Procedural Terminology

Uniformity Law:

MSSNY should take all the steps, including legislation, necessary to assure that health plans comply with and abide by the American Medical Association coding policy statements that are contained in the yearly AMA CPT coding manual.  (HOD 2007-61)

165.908           Insurer Practices Oversight by the Appropriate State Agencies:

MSSNY will seek legislation, regulation or other appropriate means to prohibit health insurance companies from unilaterally changing any material contract provision; and, if unable to obtain such change to the law, seek to assure that such material contract changes are reviewed and subject to prior approval by appropriate state agencies, including the Departments of Health and Insurance, with interested groups being given the opportunity to provide comment. (HOD 2007-58; Reaffirmed HOD 2011-57)

165.909           Psychiatric Medication Formulary Exclusion:

MSSNY should: (1) promote passage of legislation that would allow patients who, based upon the judgment of the treating physician, demonstrate stability on current medication regimens not be required to be subjected to therapeutic equivalent changes based on formulary preferences; and (2) work with the Insurance Department and the Health Department to enable a patient or physician to request an exemption from a health plan when the required drug is placed on a high-cost tier.  (HOD 2007-56)

165.910           Codification and Access of All Formularies:

MSSNY will:  (1) advocate for the creation of a unified industry-supported website that lists the formularies of all health plans and Part D plans; (2) explore the feasibility of requiring a plan to format their formularies in a nationally recognized standard that would facilitate physician Electronic Medical Record interfaces; and (3) seek to assure that health plan prior authorization rules for prescribing medications be clear and concise.  (HOD 2007-55)

165.911           Physician’s Ability to Refer to Imaging Center of Choice:

MSSNY will – (1) ask the New York State Department of Health and the New York State Insurance Department to investigate whether there are adverse health care consequences for patients as a result of managed care organizations: a) removing the ability of a physician to refer a patient to the imaging center of their choice and b) scheduling imaging services without the input of the referring physician; and (2) endeavor to limit the ability of third parties to intrude into the clinical-decision making authority of physicians.  (Council 11/2/06; Reaffirmed HOD 2016)

165.912           Electronic Data Interchange (EDI) for Claims Appeals:

MSSNY will draft model legislation requiring each managed care organization to establish an electronic data interchange (EDI) function through which physician participants can appeal denied claims, online or via a secure web-based Internet site, and since this EDI claims appeal project would significantly reduce costs for employee health insurance, MSSNY enlist the support of the appropriate New York State Employer Association.  (HOD 2006-254; Reaffirmed HOD 2016)

165.913           Protection Against Being Assigned:

MSSNY will seek legislation, regulation or other appropriate means to assure that any managed care company or other entity which assigns its provider network, to promptly notify all entities to which the services of that provider has been assigned, and that such legislation or regulation specify that a managed care company or other entity be responsible for any financial loss suffered by a physician because of a lack of prompt notification by such managed care company or entity that the physician resigned from such network.  (HOD 2006-64; Reaffirmed HOD 2016)

165.914           Standardized Managed Care Participating Agreements

MSSNY will seek regulation requiring managed care organizations licensed to do business in New York, to utilize standard physician participation agreements containing easily identifiable contract provisions, with clearly delineated standard disclosures, thereby enabling physicians to have a clear understanding of their rights and responsibilities as well as the rights and responsibilities of the contracting entity; and that if an insuring entity elects to incorporate a provision in a participating physician agreement which may depart from the norm of a standard contract provision, i.e., allowing that entity to assign/sell their listing of participating physicians to other entities (a concept referred to as a “silent PPO”), that these provisions be included in a separate and easily identifiable section of the contract.  (HOD 2005-252; Reaffirmed HOD 2015)

165.915           “Indentured Servitude” with Managed Care Organizations (MCOs) and Third-Party Administrators (TPAs)

MSSNY will seek legislation to require MCOs and TPAs to notify physicians when their contract with the MCO or TPA has been assigned and the amount of the discount fee schedule associated with the assignment of said contract. (HOD 2005-63; Reaffirmed HOD 2006-64; Reaffirmed HOD 2016)

165.916         Patient Responsibility for Services Denied by Managed Care Organizations due to Coverage Parameters

MSSNY encourages all managed care organizations licensed in this state, to adopt a policy allowing participating physicians to bill patients for those services that have been denied due to the company’s internal coverage parameters, provided that the patient knew in advance that the procedure would not be covered and still chose to have the procedure performed.  (Council 6/3/04; Reaffirmed HOD 2014)

 

165.917           Carriers’ Failure to Obey PHL 4406-c (5A) Release of Fee Schedule:

MSSNY will work with the NYS DOH to amend appropriate provisions of law to assign monetary penalties for failure to comply with requests for fee schedules.  Failing legislative relief, MSSNY will study the feasibility of bringing appropriate legal action against carriers in New York who are identified as refusing to provide requested fee schedule data.  (HOD 2003-52; Reaffirmed HOD 2013; Reaffirmed HOD 2016-56)

165.918           Time Limit for Retrospective Denials:

MSSNY continues in its efforts to seek legislation, regulation or other appropriate means to prohibit retrospective refund requests by heath plans in all circumstances except fraud.  Short of achieving a complete ban on retrospective refund requests, MSSNY seek legislation, regulation or other appropriate means to limit to 90 days the time within which a health plan can seek such a refund, or other significant restrictions on the ability of health plans to seek such refunds, such as limiting the time that a health plan can seek a refund to the same time that a physician has to file a claim with such health plan.  (HOD 2003-69; Reaffirmed HOD 2013)

165.919           The Elimination of “Silent PPOs”:

MSSNY will seek legislation:

  1. to prohibit a health plan from selling, renting or assigning a physician’s agreement to provide a discount without the physician’s expressed approval;
  2. ensuring that a panel or network physician’s services be subjected to a fee discount only when the patient presents an insurance identification card identifying the plan that has contracted with the physician; and
  3. to make “silent PPOs” unlawful in New York State. (HOD 2002-270; Reaffirmed HOD 2013)

165.920           Adoption of the Use of Unlisted Procedure Code Series in the Referral Process for Managed Care and Private Insurers:  SUNSET HOD 2013

165.921           Fee Schedules:  SUNSET HOD 2013

165.922           Resolution to Allow Complete Treatment:  SUNSET HOD 2013

165.923           Approval by Insurance Companies to Providers:

MSSNY will seek legislation assuring that insurance companies remain obligated to pay for all services that have been pre-authorized, unless such authorization was obtained fraudulently.  (HOD 2002-73; Reaffirmed HOD 2004-83; HOD 2007-67; HOD 2008-50)

165.924           Health Plan Fee Schedule Releases:

MSSNY will continue to monitor the activities of health plans as they pertain to the violation of Section 4406-c (5-a) of the New York State Public Health Law, specifically, the refusal of health plans to release their fee schedules to physicians; and will continue to encourage members to report to the MSSNY’s Official Legal Counsel, Kern Augustine Conroy & Schoppmann, PC, health plans that violate Section 4406-c (5-a) of the New York State Public Health Law.  (HOD 2001-259; Updated 2011 HOD)

165.925           Use of Federal Surpluses for Uninsured Americans: SUNSET HOD 2013

165.926           Deductible Should Be Prorated to Make Them Equitable for Enrollees:

It is MSSNY’s policy that the New York State Department of Insurance require insurers to prorate annual deductibles to the date of contract enrollment.

MSSNY introduced a resolution asking the American Medical Association’s House of Delegates to seek legislation, regulation or other appropriate relief to require insurers to prorate annual deductibles to the date of contract enrollment.  (HOD 2001-67; Reaffirmed HOD 2011)

165.927           Physicians Should Not Be Financially Liable in Retrospective Denials:

MSSNY will seek, by legislation, regulation, or other appropriate means, the following:

(a)        To prohibit retrospective denials caused by the employer’s failure to pay premiums in a timely fashion, or the employer failing to provide the carrier with timely and correct eligibility data.

(b)        To prohibit a payor from attempting to retroactively deny or adjust a claim after payment is made to a physician for care rendered.

(c)        That should obtaining a complete ban on retrospective denials or adjustments not be able to be enacted, seek to prohibit insurers from making a retroactive denial and/or adjustment of a reimbursement beyond 90 days after payment is made to the physician for care rendered.

(d)        In the event that an insurer attempts to issue a retroactive denial or adjustment after payment is made to the physician, to require such insurer to provide the physician with a detailed explanation on each patient as to the circumstances surrounding the retroactive adjustment or reimbursement and/or denial, and provide the physician with an effective opportunity to counter the reasons for the adjustment.

(e)        In the event that an insurer has already paid the physician for a service, but later issues a retrospective denial or adjustment, to prohibit such insurer from attempting to recoup its payments for that service via offsets on payments for other services.

MSSNY will work regularly with all appropriate regulatory agencies to insure that the regulators are kept apprised of payment policies employed by plans which do not comport with the law.  (HOD 2001-65; Reaffirmed HOD 2010-259)

165.928           Rejection of Milliman & Robertson as Standard of Care

MSSNY formally rejects the Milliman & Robertson guidelines as a standard of care.  (HOD 2000-273; Reaffirmed HOD 2014)

165.929           Health Plan’s Improper and Bullying Techniques to Force Physicians to Inappropriately Downcode E&M ServicesSUNSET HOD 2014

165.930           Health Insurance Eligibility Electronic Verification System:

MSSNY will seek legislation requiring all health care plans doing business in New York State to issue health insurance cards containing magnetic strips, which can be used with an electronic verification system which would be furnished to physicians free of charge by the health care plans.  (HOD 2000-272; Reaffirmed HOD 2014)

165.931           Managed Care Organizations Should Supply Complete Fee Schedules and Include Cost of Living Adjustment (COLA) Guarantees in ContractsSUNSET HOD 2014

165.932           Health Care Plans:

MSSNY will seek regulation and/or legislation that once a health care plan has sold its product to a consumer, the health care plan is not permitted to limit the territory it covers during the policy term.  (HOD 2000-254; Reaffirmed HOD 2014)

165.933           Downcoding:

MSSNY will seek legislative relief to (a) preclude down-coding and/or bundling of any medically necessary service by health care plans doing business in New York State and Computer Sciences Corporation/Medicaid; (b) prevent health care plans and Computer Sciences Corporation/Medicaid from the down-coding of medical services without first obtaining, at the expense of the health care plan, copies of patients’ medical record and justifying the change in reimbursement; (c) prevent health care plans and Computer Sciences Corporation/Medicaid from requiring automatic and mandatory submission of medical record documentation for Evaluation and Management (E&M) codes at the time of claim submission.  (HOD 2000-253; Reaffirmed HOD 2013; Reaffirmed HOD 2014)

165.934           AMA Policy on ERISA:  (Please note that the original position statement cited policy H-165.882 which has since been significantly modified and original policy H-165.883 which no longer exists.)

MSSNY affirms the following AMA Policy:

H-165.882 Improving Access for the Uninsured and Underinsured

Our AMA:  (1) Will assist state medical associations and local medical societies to work with states and the insurance industry to design value-based private group and individual health insurance policies.  Such policies should cover with low cost-sharing those services adjudged to have the greatest health benefit, should be affordable, and should be equivalent to or an improvement over the Medicaid coverage in that state, so as to provide a continuum of gradually enhanced coverage.  (2) Supports federal legislation to encourage the formation of small employer and other voluntary choice cooperatives by exempting insurance plans offered by such cooperatives from selected state regulations regarding mandated benefits, premium taxes, and small group rating laws, while safeguarding state and federal patient protection laws.  Any support for such small employer and voluntary purchasing cooperatives shall be strictly contingent upon safeguarding state and federal patient protections.  For purposes of such legislation, small employers should be defined in terms of the number of lives insured, not the total number employed.  (3) Through appropriate channels, encourages unions, trade associations, health insurance purchasing cooperatives, farm bureaus, fraternal organizations, chambers of commerce, churches and religious groups, ethnic coalitions, and similar groups to serve as voluntary choice cooperatives for both children and the general uninsured population, with emphasis on formation of such pools by organizations which are national or regional in scope.  (4) Supports continued study of all approaches to providing health services for the uninsured and cooperation with business groups to develop approaches that are best suited to the needs of small employers.  (5) Encourages physicians, through their local county medical societies, to explore ways to work within their communities to address the expanding problem of inadequate access to care for the uninsured and underinsured and openly communicate with one another to share information about successful programs. (CMS Rep. C, I-86; BOT Rep. JJ, A-89; Reaffirmed: Sub. Res. 110, A-94; Reaffirmed: CMS Rep. 6, I-96; CMS Rep. 7, A-97; Amended by CMS Rep. 9, A-98; Reaffirmation I-98; Reaffirmation A-99; Reaffirmed: CMS Rep. 5, I-99; Reaffirmed: Res. 238 and Reaffirmation A-00; Modified: BOT Rep. 17, I-00; Reaffirmation A-02; Res. 102, A-05; Consolidated: CMS Rep. 7, I-05; Modified: CMS Rep. 8, A-08) ,(Modified MSSNY HOD 2011)

165.935           HMO Carve-outs:  SUNSET HOD 2014

165.936           Mandated Use of Hospitals by Managed Care CompaniesSUNSET HOD 2014

165.937           Full Adoption of the National Specialty Societies’ Practice Parameter Guidelines by Third-Party Insurers

MSSNY will seek legislative or regulatory relief to require third-party insurers in New York State to utilize practice guidelines for utilization review purposes as developed by the appropriate national or state specialty societies.  (HOD 2000-72; Reaffirmed HOD 2003-268 & 278; Reaffirmed HOD 2013)

165.938           Patient’s Choice:

MSSNY will seek New York and Federal legislation which requires a health care plan to permit patients to access, without restriction, any and all providers participating with the plan who provide medical or diagnostic services. (HOD 2000-63; Reaffirmed HOD 2014)

165.939           Insurance Company Participating Provider Networks:

MSSNY will pursue a legislative remedy to ensure that when any health care plan entity publishes a list of participating providers as part of an advertising campaign to enroll new members for a future time period (or upcoming coverage period), that said list accurately reflect the physicians who will be participating during the time period the insurance will be in effect and not merely the physicians who are currently participating as of the time of the advertising campaign.  (HOD 2000-62; Reaffirmed HOD 2014)

165.940           Full Disclosure of All Documents Related to Third-Party Insurer

Contracts

MSSNY will seek legislation, regulation and/or enforcement of current laws and regulations to allow for informed decision-making by physicians. MSSNY urges third-party payors to provide all pertinent information prior to the signing of any participation agreement including the provision of the fee schedule. (HOD 2000-61; Reaffirmed HOD 2001-258; Reaffirmed HOD 2003-268 & 278; Modified and reaffirmed HOD 2013)

165.941           Coordination of Pharmacy Benefit into Existing Health Plans

MSSNY will seek legislation which would preclude health care plans from requiring physicians to deviate from an already established drug regimen (formulary) based solely upon cost factors associated with less expensive, but possibly less effective drugs.  The aforementioned legislation should include coordination of a pharmacy benefit into already existing health plans.  MSSNY will strongly encourage the development and utilization of technologies to allow physicians to instantly access the established drug of any health plan with which the physician maintains a contractual relationship. (HOD 2000-56; Reaffirmed HOD 2001-53; Reaffirmed HOD 2011; Reaffirmed HOD 2015-57)

165.942           Education About HMOs as Payors for Health Care:  SUNSET HOD 2014

165.943           Require Health Insurance Carriers to Report Medical Loss Data that Reflects All Levels of Managed Care SubcontractingSUNSET HOD 2014

165.944           HMO Requirements that Physician Providers Use Only Approved Laboratories: SUNSET HOD 2014

165.945           Qualification of Precertification Reviewers:

MSSNY will support legislation requiring MCOs to utilize New York State practicing physicians as pre-certification reviewers.  MSSNY shall support legislation requiring that any pre-certification denial be reviewed by a physician in active practice in New York State in the same specialty or subspecialty as the physician performing the procedure, and that such legislation include provisions which would require managed care organizations to utilize medical protocol and review criteria approved by New York State practicing physicians who participate in the plan.  (HOD 1999-91; Reaffirmed HOD 2011-107)

165.946           Information Included on Health Insurance Identification Cards:

MSSNY reaffirms its commitment to the positions embodied in Resolution 97-56, (Policy 165.981) and, in addition, MSSNY will work with payors to encourage the use of “smart cards” which would encode information, including but not limited to, the patient’s eligibility data, co-pay, type of policy, effective policy dates, company address and appropriate phone number, I.D. number, group number, and the name of any entities with whom the MCO has subcontracted to pay for specific “carved-out” services.  MSSNY will work with payors to encourage the use of  a standard encryption format so that one machine is capable of reading data from all companies, and that the smart card reader be made available to all physicians at a reasonable price.  MSSNY will seek through legislation or regulation a requirement that payors provide immediately, upon application for enrollment, a temporary health insurance identification card providing information including but not limited to notice of effective date of eligibility.  (HOD 1999-87; Reaffirmed HOD 2000-272; Reaffirmed HOD 2014)

165.947           HMO Physician Indemnification:

MSSNY will seek legislation requiring health care plans to indemnify and hold harmless a participating physician who acts in good faith and is sued by an insured patient for outcomes that result when the physician’s recommended course of action has been denied by the health care plan.  (HOD 1999-81; Reaffirmed HOD 2014)

165.948           Community Rating for Medical Coverage:

MSSNY will work with the American Medical Association to secure passage of federal legislation to:  (a) replace the current tax exclusion of employer-provided coverage with a refundable tax credit for each individual who receives coverage as a benefit of employment, or who purchases health insurance in the private market;  (b) expand the definition of health benefits under Section 106 of the Internal Revenue Code to include employers’ contributions to their employees’ purchase of individual health insurance;  (c) eliminate the restrictions on the availability of MSAs; and,  (d) enable the creation of risk pooling cooperatives to foster an environment in which individually owned insurance could be purchased economically.  MSSNY will support all legislative/ regulatory efforts to examine the need to implement effective state insurance reform that would facilitate the purchase of individual and group coverage for all New Yorkers at an affordable cost. (HOD 1999-68; Reaffirmed HOD 2014)

165.949           Quarterly Publication of Supplementary Provider Lists for HMO Subscribers:
                        SUNSET HOD 2014

165.950           Require that HMO Subscribers Select a Primary Care Physician Within 30 Days or be Assigned One by the Plan, as per the Requirements of the NYS Medicaid Managed Care Guidelines Issued by the NYS Department of Health:

MSSNY will seek regulatory or legal action to require that if HMO subscribers do not select a primary care physician within thirty days, they be assigned one by the plan, similar to the current guidelines utilized by the NYS Department of Health governing Medicaid Managed Care Plans; and such regulatory or legal action should also require that HMOs inform each enrollee of the name, address, and telephone number of the primary care physician to whom the enrollee has been assigned and of the enrollee’s right to select a different primary care physician.  MSSNY will seek regulatory or legal action to require that payment of the capitated amount to the primary care physician begin at the time of selection or assignment.  (HOD 1999-62; Reaffirmed HOD 2014)

165.951           Quarterly Financial Disclosures:

MSSNY will seek the introduction of legislation and/or regulation to require HMOs and insurance companies to provide quarterly:  a standard financial report, a statement of financial reserves, and a statement of outstanding debt including “disputed” and “undisputed” claims to the Medical Society of the State of New York and that MSSNY shall seek the introduction of legislation and/or regulation to require HMOs and insurance companies to report to the State all transfers of funds in excess of $250,000 not in the ordinary course of business within 15 days of such transfer and that such legislation and/or regulation should require HMOs and insurance companies to provide, upon request by MSSNY, an independent audit of a quarterly report when in the quarter for which the report was issued, such plan has transferred funds in excess of $250,000 not in the ordinary course of business.  (HOD 1999-59; Reaffirmed HOD 2014)

165.952           Managed Care Organizations’ Restricting Practice of Credentialed Physicians: 

MSSNY will seek legislation or regulation barring managed care organizations from limiting, by internal policy or refusal of payment, qualified physicians from practicing within the scope of their abilities, license and training.  (HOD 1999-54; Reaffirmed HOD 2014)

165.953           Accountability for HMO Termination of a Physician by Mistake:

MSSNY will actively seek legislation or regulation which holds an HMO or managed care plan accountable for all damages incurred by a physician as the result of termination notification which was made in error, to the physician’s patients.  MSSNY will take all action necessary to assure that physicians are informed of their rights when terminated by a plan or when patients are inappropriately notified of a physician’s termination from the plan.  (HOD 1999-53; Reaffirmed HOD 2007-254)

165.954           Prudent Layperson – 911 Calls:

MSSNY reaffirms its support of the prudent layperson standard for emergency medical service and opposes triage by 911 dispatch which divert 911 (Emergency Dispatch) calls to non-emergency facilities, other than birthing centers or those facilities identified by the local REMAC (Regional Medical Advisory Committee) because of geographic constraints.  (Council 10/28/98; Reaffirmed HOD 2014)

165.955           The Need for Patients to be Informed as to the Difference Between Physicians and Other Types of Health Care Provides so as to Allow the Patient to Make a  Choice of a Physician or Other Health Care Provider Based in Informed Consent

MSSNY shall seek enactment of State and Federal legislation mandating that patients be notified whenever a health care provider other than a physician will provide care to a patient.  (HOD 1998-57, Reaffirmed HOD 1999-83; Reaffirmed HOD 2014)

165.956           Disclosure of Conversion Options by Medicare Managed Care Organizations to Prospective Enrollees Previously Covered by Employer-Sponsored Insurance ContractsSUNSET HOD 2014

165.957           Re-credentialing of Physicians in Merged Managed Care Organizations:

The Medical Society of the State of New York will seek to assure, through whatever means appropriate, that when a contract between a managed care organization and credentialed physicians is transferred, merged or consolidated into another organization, the cost associated with re-credentialing of already credentialed participating physicians be borne by the new entity.  (HOD 1998-207; Reaffirmed HOD 2014)

165.958           Crediting Capitated Payment:

MSSNY will advocate for legislation and/or regulations requiring managed care plans (a) to begin capitated payments to the physician starting from the date of which the patient enrolls in the managed care plan; (b) that the enrollee designate a primary care physician in a timely manner and (c) that the physician be notified of such selection.  (HOD 1998-83; Reaffirmed HOD 2014

165.959           Channeling of Eye Examinations to Optometrists:

It is the position of MSSNY that third-party payors not be permitted to shift patients from ophthalmologists to optometrists, that third-party payors not designate optometrists as primary eye care providers; and that MSSNY will issue a letter to all third-party payors operating in New York State, putting forth organized medicine’s strong opposition to channeling enrollees to optometrists and other non-physicians and opposing the exclusion of ophthalmologist from refractive eye examinations, routine eye examinations, or primary eye care.

MSSNY will coordinate efforts with medical specialty societies to introduce legislation prohibiting third-party payors from mandating or encouraging that routine and refractive examinations be performed by optometrists rather than by ophthalmologists.  (HOD 98-79; Reaffirmed HOD 2014)

165.960           Capitation:

The Medical Society of the State of New York will seek legislation or regulation which (a) defines acceptable financial risk arrangements between physicians and managed care plans to minimize the potential for the reduction or limitation of appropriate access to medically necessary services; and (b) ensures that managed care plan enrollees be entitled to know the type of financial risk arrangement health plans have in place for their providers.  (HOD 1998-72; Reaffirmed HOD 1999-268; Reaffirmed HOD 2014)

165.961           Enforcement of Disclosure Laws Under Managed Care Bill of Rights:

That the Medical Society of the State of New York petition the state legislature, Attorney General, and the Governor to (a) strictly enforce the current law and (b) increase the

fine to a sufficient level to encourage compliance and (c) clearly stipulate that such fines shall not be paid from money budgeted for the provision of health care. (HOD 1998-61; Reaffirmed HOD 2014)

165.962           State Control Over Changes in Health Insurance Coverage and Reimbursement:

MSSNY will seek the enactment of legislation that

(a) requires that physicians receive specific notice of the compensation terms proffered by managed care plans, including a detailed statement of the precise terms by which monies will be paid and

(b) requires that physicians be routinely informed of the method by which the amount of a withhold or a bonus will be calculated, the date upon which payment will be made and a description of the records relied upon to calculate the withhold or bonus and

(c) requires scrutiny of managed care plans financial statements by appropriate state agencies when a managed care plan fails to return funds withheld from physicians in a given year to determine if the retention of funds by the managed care plan is, indeed, justified and

(d) if retention of funds is determined to be unjustified, said agencies direct the managed care plan to return the withhold with appropriate interest and penalties, and

(e) inform beneficiaries when benefits are changed.  (HOD 1998-60; Reaffirmed HOD 2014)

165.963           Public Disclosure of Telephone Triage Protocols by MCOs:  SUNSET HOD 2014

165.964           Formation of a Special and/or Public Commission to Monitor Managed Care:
SUNSET HOD 2014

165.965           Repeal of ERISA Exemption for HMO Tort Liability:  SUNSET HOD 2014; see 165.968 and 165.969

165.966           Uniform Application Form, Uniform Encounter Form:

MSSNY supports the establishment and use of a uniform application and a uniform encounter form to be used by all HMOs, IPOs, HPOs and IPAs.  (HOD 97-273; Reaffirmed HOD 2014)

165.967           Managed Care Organizations to Standardize Pre-Certification:

MSSNY will encourage managed care organizations to standardize pre-certification procedures and time limits for HMOs to respond to pre-certification requests for patient care regardless of the time of day or day of week.  (HOD 1997-254; Reaffirmed HOD 2014)

165.968           Liability of Managed Care Entities As Well As Their Employees, Agents, Ostensible Agents And Representatives:

MSSNY will develop or support legislation or regulation requiring that whenever an employee, agent, ostensible agent and/or representative of a managed care entity makes a determination that affects a patient’s health, both the individual and the entity should be held liable for any adverse outcome to the patient arising directly from the determination or as a consequence of the determination.  (HOD 1997-114; Reaffirmed HOD 1998-84; Reaffirmed HOD 2014; Reaffirmed HOD 2015-57)

165.969           Managed Care Companies and The Practice Of Medicine Without A License:

MSSNY will support legislation or regulation that will declare that any person making decisions on the medical necessity or appropriateness of care affecting the diagnosis or treatment of a patient in New York must have a license to practice medicine in New York; and that a physician making decisions on the medical necessity or appropriateness of care affecting the diagnosis or treatment of a patient in New York without a valid New York license, as well as the company that employs him/her, will be subject to investigation, criminal prosecution and possible fines.  (HOD 1997-112; Reaffirmed HOD 1998-62; Reaffirmed HOD 2014; Reaffirmed HOD 2015-57)

165.970           DEA Numbers Should Not Be Used As A Means Of Physician

Identification:

MSSNY will advise and encourage New York State physicians not to release their DEA numbers except where required for prescribing narcotics and other Schedules II-V drugs; and will advise all MCOs of this policy.  In the event that MCOs persist in using the DEA number as a means of physician identification, MSSNY will vigorously pursue appropriate legislative or regulatory relief and will ask the AMA to pursue similar legislation or regulatory relief.  (HOD 1997-107; Reaffirmed HOD 2000-60; Reaffirmed HOD 2014)

165.971           Retrospective Denial of Insurance Claims:

MSSNY will seek legislation which would amend subdivision (4) of section 4903 of the public health law and subdivision (d) of section 4903 of the insurance law which require health maintenance organizations and insurers to “make a utilization review determination involving a health care service which has been delivered within 30 days of receipt of the ‘necessary information’” to further require that in no event shall such determination be made later than 90 days from the submission of the claim.  (HOD 1997-97; Reaffirmed HOD 2014)

165.973           Patient Access to Physicians No Longer On Plan:

MSSNY will seek legislation which would enable enrollees to a managed care plan to continue to receive care from the enrollee’s current physician for up to one year or the balance of their policy period, whichever is longer, where the physician has left or has been terminated by the plan provided that the termination is not related to imminent harm to patient care, a determination of fraud or a final disciplinary action and provided further that the physician continues to accept reimbursement from the managed care plan at the rates applicable prior to the termination or departure of such physician from the plan and adheres to the plan’s quality assurance and utilization review requirements. (HOD 1997-93; Reaffirmed HOD 2014)

165.974           “Hold Harmless” Protection for Physicians Under Contract:

MSSNY will included in its policies and practices educating the physician on how such “Hold Harmless” clauses can serve to protect the physician or to increase risk exposure. (HOD 1997-79; Reaffirmed HOD 2014)

165.975           Retroactive Denials:

MSSNY working through the Committee on State Legislation will strongly support the introduction of appropriate legislation to require all health insurers in this State, including HMOs, to be precluded from retroactively denying reimbursement to physicians for patients’ admissions to hospitals.  (HOD 1997-78; Reaffirmed HOD 2014)

165.976           Substituting Nurse Practitioners For Licensed Primary Care Physicians:

MSSNY will seek legislation prohibiting the substitution of licensed primary care physicians with nurse practitioners, and will continue its public opposition to replacing physicians with physician extenders.  In recognition of a patient’s right to receive high quality medical care from appropriately trained health care professionals, and the lack of any credible studies which indicate that services provided by nurse practitioners are equal to those rendered by physicians, MSSNY will communicate to all appropriate state agencies and state officials its opposition to the Oxford Health Plan agreement with Columbia University and Presbyterian Medical Center and to similar activities engaged in by other managed care entities operating in New York State.  (HOD 1997-71; Reaffirmed HOD 2014)

165.977           Financial Incentives Based Upon The Non Provision Of Services:

MSSNY will seek legislation which would prohibit the use of any financial incentives which inhibit the provision of medically necessary care.  (HOD 1997-68; Reaffirmed HOD 2014)

165.978           Referrals To Allied Health Providers:

It is the position of MSSNY that managed care organizations in the State of New York should be required to designate only MDs and DOs as primary care providers for any individual or group of patients.  MSSNY will continue its public opposition to replacing physicians with physician extenders;  and will communicate its opposition to the assignment of primary care status to any professional provider other than an MD or DO in managed care entities and workers compensation programs operating in New York State.  (HOD 1997-64; Reaffirmed HOD 2014)

165.979           Elimination of the Managed Care Requirement to Obtain a Referral from a Primary Care
                         Physician Prior to Utilizing the Services of a Specialist
:
                       SUNSET HOD 2013

165.980           Dismissals for Cause in Managed Care Contracts:

The Medical Society of the State of New York shall seek legislation that no terminations or non-renewals of physician contracts with managed care plans shall be valid without cause, and will seek the introduction of legislation which would require managed care plans to provide all physicians with a fair and equitable due process appeal if they are excluded from a managed care plan regardless of the reasons for such exclusion and irrespective of whether such exclusion is considered to be a termination or a non-renewal.  Such due process hearing shall be held before a panel which is composed of three New York State licensed physicians, one of whom is chosen by the plan, one of whom is chosen by the physician who is the subject of the hearing, and the third who is chosen by the other two members of the panel.  At this hearing, the physician shall be entitled to be advised of the reason for his de-selection and shall be provided with:  (a)  the opportunity to be represented by counsel, and   (b)  the right to call witnesses and present evidence in support of this position.  (HOD 1997-53; Reaffirmed HOD 2014)

165.981           Toll-Free Telephone Numbers to be Required for all Health Insurance Carriers to Provide
                         Access for Participating Physicians
:

The Medical Society of the State of New York will seek legislation or regulatory action to require PPOs and self-insured plans, as well as insurers not engaged in utilization review procedures, to provide adequate personnel to respond to telephone requests from patients and physicians.  These plans should be required to have procedures that;  (a)  would require that adequate personnel to be available at least 40 hours per week during normal business hours to discuss patient care and allow response to telephone requests; and  (b)  this telephone system should be accessible on a toll-free basis for patients and physicians; and  (c)  that there be a toll-free telephone system capable of accepting, recording or providing instruction to incoming telephone calls during other than normal business hours and to ensure that a response to the accepted or recorded message occurs not more than one business day after the date on which the call was received;  (d)  and that where a plan does not provide for such reasonable and adequate access, the eligibility of a patient with an identification care from the plan will be deemed valid.  (HOD 1997-56; Reaffirmed HOD 2000-272; Reaffirmed HOD 2009-259)

165.982           Changes in the Bundling of Medical Services by Managed Care Plans:

It is MSSNY’s position that when a patient sees a physician for evaluation and management of an illness, whether primary care or consultation, and the physician also performs a procedure which helps in the diagnosis or treatment of that illness, the physician should be paid for both the evaluation and management code and the procedure code.  When a physician sees a patient to perform a pre-scheduled procedure, cognitive services are considered part of the performance of the procedure and the physician should be paid only for the procedure.  The supporting rationale for this policy is embodied in two separate functions;  (a)  the evaluation of the problem and decision to perform a procedure; and  (b)  the performance and interpretation of the procedure.  These functions could often be performed on separate days, but, for reasons of good medicine, expedited care and patient/physician convenience, it is often preferable to perform the procedure on the same day as the evaluation and management visit.  It would, therefore, be inappropriate under these circumstances to either unnecessarily require the patient to have the procedure performed on another day or to deprive the physician of equitable payment for the proper provision of both services on the same day.  (Council 12/19/96; Reaffirmed HOD 2000-257 & 268; Reaffirmed HOD 2014)

165.983           Redefining the Roles, Obligations and Responsibilities of Insurance Companies which
                         Utilize Capitation as a Means of Physician 
Reimbursement:

MSSNY will seek legislation requiring managed care organizations to assume appropriate risk while at the same time:

(a)  providing an adequate proportion of premium dollars dedicated to medical care;

(b)  providing for equitable physician reimbursements;

(c)  reducing excessive MCO profit margins.  (Council 12/19/96; Reaffirmed HOD 2014)

165.984           Prior Authorization for Procedures Under Managed Care: Limits on Time Requirements

MSSNY supports the requirement that managed care organizations implement and comply with written procedures to assure that entities that conduct utilization review:  (1)  provide adequate access to its review staff by a toll-free or collect call phone line, at a minimum, from 8:00 a.m. of each standard business day; (2)  establishment of written procedures for receiving or redirecting after-hour calls either in person or by recording; and  (3)  having a mechanism to receive timely call backs from providers.  (HOD 1996-76; Reaffirmed HOD 2014)

165.985           “Hold Harmless” Clauses in Physicians’ Contracts with Health Care Delivery Entities:                                SUNSET HOD 2014; See 165.968 AND 165.969

165.986           Gag Rule in Managed Care Contracts  SUNSET HOD 2014

165.987           Administrative Procedures, Standardization of Managed CareSUNSET HOD 2014

165.988           Specialty Rosters in Managed Care

All managed care organizations should be required to maintain full rosters of medical specialists, representing all the specialties approved by the American Board of Medical Specialties and the American Osteopathic Board of Medical Specialties or otherwise provide access outside the managed care organizations to the full range of medical specialists as needed.  (HOD 1996-78; Reaffirmed HOD 2014)

 

165.989           Retrospective Denial of Pre-Certified Services by Managed Care:

The practice of retrospective denial of payment for care which has been pre-certified by an insurer should be banned, except when false or fraudulent information has knowingly been given to the insurer by the physician, hospital or ancillary service provider to obtain pre-certification.  (HOD 1996-90; Reaffirmed HOD 2014; Reaffirmed HOD 2016-262)

165.990           Profits and Administrative Costs of Managed Care OrganizationsSUNSET HOD 2014

165.991           Responsibility To Patients in Managed Care Plans

MSSNY will seek legislation requiring that any health plan using managed care techniques should be subject to legal action for any harm incurred by the patient resulting from application of such techniques; health plans shall also be subject to legal action for any harm to enrollees resulting from failure to disclose, prior to enrollment, any coverage provisions, review requirements, financial arrangements, or other restrictions that may limit services, referrals or treatment options, or negatively affect the physician’s fiduciary responsibility to his or her patient.  (HOD 1995-59; Reaffirmed HOD 2014)

165.992           Utilization Review Management

MSSNY affirms the following position with regard to Utilization Review Management applicable to managed care entities who utilize down-coding, site of service payment reductions, and restrictive patient referral policies as a means of economic disincentives as follows:  Physicians who are trained and/or Board Certified in their practice should be allowed to perform and be reimbursed for services if they are medically indicated.  Any managed care plan implementing utilization review or management programs should establish an appeals process whereby physicians, other health care providers and patients may challenge policies restricting access to specific services and decisions to deny coverage for services.  Such individuals must have the right to have reviewed any coverage denial based on medical necessity by a physician who is of the same specialty and has appropriate expertise and experience in the field.  Any physician who makes judgments or recommendations regarding the necessity or appropriateness of services, or site of services, should be licensed to practice medicine and actively practicing in New York State and should be professionally and individually accountable for his or her decisions.  The medical protocols and review criteria used by managed care plans in any utilization review or management program must be developed by practicing physicians.  Managed care plans should be required to disclose to physicians, on request, the screening and review criteria, weighing elements, and computer algorithms used in the review process, as well as how they were developed.  A physician of the same specialty must be involved in any decision by a utilization review or management program to deny or reduce coverage for services based on questions of medical necessity.  A physician whose services are being reviewed for medical necessity should be provided the identity and credentials of the reviewing physician on request.  The reviewed physician should also have the opportunity to speak with a reviewer.  (Council 9/22/95; Reaffirmed HOD 2000-79 & 80; Reaffirmed HOD 13-258; Reaffirmed HOD 2014)

165.993           Emergency Services at Specialty Centers – Equity Coverage by Managed Care Entities

It is the position of MSSNY that those managed medical care organizations that limit or restrict fiscal coverage to certain hospitals and physicians make an exception for emergent critical care case situations (such as extensive burns, neonatal spinal injuries, multi-organ/extensive trauma) that are sent to the appropriate specialty centers pursuant to guidelines established by organized medicine, and State or Federal policy, rules and regulations.  MSSNY strongly opposes any attempt by a managed care entity or third party payer to delay, to deny payments, or to reduce payments when a patient is sent, on an emergent basis, to a designated specialty center and will disseminate this position to the membership and the New York State Health Maintenance Organization Council.  (HOD 1994-274; Reaffirmed HOD 2014)

165.994           Policy on Managed Care

MSSNY affirms the following policy as adopted by the Council on January 23, 1986, and amended by the Committee on Interspecialty on January 13, 1994:

(1)  No single pattern of health care delivery is necessarily suited to all patients or to all physicians; and that

(2)  The traditional fee-for-service, the HMO, the HMO-IPA, and PPO concepts are valid and acceptable health care delivery systems; but

(3)  There must be available multiple delivery mechanisms among which both the patient and the physician can truly exercise the right of free choice of how they will receive and disburse quality medical care; and that

(4)  Any managed care plan is urged to cover in its basic policy all medically necessary procedures for all ICD-9 illnesses; medical, surgical, psychiatric and addictive.  In the presence of such parity, cost factors may be dealt with by practice parameters, by utilization criteria and review, and by sliding scales of co-insurance and deductibles, not by limiting areas or specialties of care; and that

(5)  Employers should contribute equitable amounts for each employee’s health benefit plan, regardless of the plan selected; and that

(6)  Fair market competition among all systems of health care delivery shall continue to be MSSNY policy (similar to AMA policy) with the potential growth of health care delivery systems being determined not by governmental intercession or entrepreneurial considerations, but by the number of people who prefer this mode of delivery.  In addition, MSSNY recognizes both closed panel plans and open panel plans as valid and acceptable health care delivery modalities, consistent with the foregoing MSSNY policy statement.

MSSNY affirms the following AMA policy statements on managed care encompassing: (1) Case Management; (2) Financial Incentives and Disincentives;  (3) Selective Contracting; (4) Physician Governance of Managed Care Program Policies:

1)  Case Management  (a)  Case Management Health plans using the preferred provider concept should not use coverage arrangements which impair the continuity of patient’s care across different treatment settings.  (b)  With the increased specialization of modern health care, it is advantageous to have one individual with overall responsibility for coordinating the medical care of the patient.  The physician is best suited by professional preparation to assume this leadership role.  (c)  The Primary goal of high-cost management or benefits management programs should be to help to arrange for the services most appropriate to the patient’s needs; cost containment is a legitimate but secondary objective.  In developing an alternative treatment plan, the benefits manager should work closely with the patient, attending physician, and other relevant health professionals involved in the patient’s care.  (d)  Any health plan which makes available a benefits management program for individual patients should not make payment for services contingent upon a patient’s participation in the program or upon adherence to treatment recommendations.  (AMA Policy 285.998)

2)  Financial Incentives and Disincentives  (a)  Any financial arrangements that may tend to limit the services offered to patients, or contractual provisions that may restrict referral or treatment options, should be fully disclosed to prospective enrollees by plans utilizing such arrangements.  (b)  Physicians must disclose any financial inducements or contractual agreements that may tend to limit the diagnostic and therapeutic alternatives that are offered to patients or restrict referral or treatment options.  Physicians may satisfy their disclosure obligations by assuring that the managed care plan makes adequate disclosure to patients enrolled in the plan. Physicians must also inform their patients of medically appropriate treatment options regardless of cost or the extent of their coverage.  (c)  Physicians should have the right to enter into whatever contractual arrangements with health care systems they deem desirable and necessary, but should be aware of the potential for some types of systems to create conflicts of interest because of financial incentives to withhold medically indicated services.  Physicians must not allow such financial incentives to influence their judgment of appropriate therapeutic alternatives or deny their patients access to appropriate services based on such inducements.  (d)  Physician payments that provide an incentive to limit the utilization of services should not link financial rewards with individual treatment decisions over periods of time insufficient to identify patterns of care or expose the physicians to excessive financial risk for services provided by physicians or institutions to whom he or she refers patients for diagnosis or treatment.  When risk-sharing arrangements are relied upon to deter excess utilization, physician incentive payments should be based on performance of groups of physicians rather than individual physicians, and should be based over short periods of time.  (e)  Alternative private health benefit plans, with different schedules of deductibles, coinsurance and premiums, should be available to enrollees so that they are aware of the financial trade-offs associated with different plans.  Both private and public third party payment systems should use deductibles and coinsurance as financial incentives for health care recipients to use health care resources in an appropriate manner.  However, cost-sharing should not result in an undue financial burden for the health care recipient , and should not act to prevent access to needed care.  (f)  Physicians, other health professionals, and third party payors through their reimbursement policies, should continue to encourage use of the least expensive care setting in which medical and surgical services can be provided safely and effectively with no detriment to quality.  (AMA Policy 285.998)

3)  Selective Contracting  (a)  Health plans or networks should provide public notice within their geographic service areas when applications for participation are being accepted.  (AMA 285.998)  (b)  Physicians should have the right to apply to any health care plan or network in which they desire to participate and to have that application judged on the basis of objective criteria that are available to both applicants and enrollees. (AMA CMS Report B, A-93)  (c)  Those managed care plans that contract with selected physicians to furnish care should utilize selection criteria based primarily on professional competence and quality of care.  Any economic criteria used in such selective contracting should have a demonstrated positive relationship to the quality and appropriateness of care and to professional competency. (AMA Policy 285.997)   (d)  Managed care plans that contract with selected providers should have an established appeals mechanism by which any provider willing to abide by terms of the plan contract could challenge a decision to deny the provider’s application for participation in the plan.  (AMA Policy 285.997)  (e)  All managed contracts should expressly require the managed care plan to provide meaningful due process protections, in order to prevent wrongful and arbitrary contract terminations that leave the physicians without means of redress.  (AMA Policy 285.996)  (f)  Prior to initiation of actions leading to termination or non-renewal of a physician’s participation contract for any reason, the physician shall be given notice specifying the grounds for termination or non-renewal, a defined process for appeal, and an opportunity to initiate and complete remedial activities except in cases where harm to patients is imminent or an action by a state medical board or other government agency effectively limits the physician’s ability to practice medicine.  (AMA CMS Report B, A-43)  (g)  All “hold harmless” clauses in managed care contracts should be explicitly identified as such.  Physicians should consider consulting with legal counsel prior to contracting with a managed care entity to prevent the imposition of unfair liability upon the physician.  (AMA Policy 285.995)  (h)  Physicians should have the right to enter into whatever contractual arrangements with managed care plans they deem desirable and necessary, but should be aware of the potential for some types of plans to create conflicts of interest because of financial incentives to withhold medically indicated services.  (AMA Policy 285.998)

4)  Physician Governance of Managed Care Programs’ Policies  (a)  The medical protocols and review criteria used in any utilization review or utilization management programs must be developed by physicians.  (AMA Policy 285.998)

In addition it is the position of MSSNY that quality assurance policies and any medical protocols be governed by practicing physicians. Credentialing of physicians is directly related to utilization review and quality assurance, and should, therefore, be operated in accordance with policies determined by physicians.  (Council 3/10/94; Reaffirmed HOD 2014)

165.995           Organized Medical Staffs in Managed Care Entities:

It is MSSNY policy that managed care entities establish self-governing medical staffs similar, if not identical, to those in hospitals.  The principles of self-governance should include, but not be limited to:

  • the development of medical Staff Bylaws which cannot be unilaterally changed by the governing of managed care entity;
  • physician selection representatives to the governing board and other appropriate committees of managed care entities including credentialing, privileging, quality assurance and utilization review committees;
  • due process protections for physicians credentialed by a managed care entity; and full indemnification by managed care entities of physicians who, in good faith, serve as members of credentialing, quality assurance and utilization review committees of managed care entities. (HOD 1994-102; Reaffirmed HOD 2014)

165.996           Personal Financial Gain Should Not Influence Medical Decisions

It is MSSNY policy that decisions involving medical care should be based upon the medical needs of the patient and independent of physician financial incentives and disincentives.  (Council 9/22/94; Reaffirmed HOD 2014)

165.997           Physician Participation in Managed Care Plan

MSSNY reaffirms current policy on managed care adopted by the Council on March 10, 1994 which is consistent with AMA policy and addresses the right of any physician to seek participation in any health care system.  The relevant provisions of this policy read as follows:

(1)  Physicians should have the right to join any health care plan or network in which they desire to participate and to have that application judged on the basis of objective criteria that are available to both applicants and enrollees.

(2)  Those managed care plans that contract with selected physicians to furnish care should utilize selection criteria based primarily on professional competence and quality of care.  Any economic criteria used in such selective contracting should have a demonstrated positive relationship to the quality and appropriateness of care and to professional competency.

(3)  Selective contracting decisions made by any health delivery or financing system should be based on an evaluation of multiple criteria related to professional competency, quality of care, and the appropriateness by which medical services are provided.  In general, no single criterion should provide the sole basis for selecting, retaining, or excluding a physician from a health delivery or financing system.

MSSNY further espouses the policy that no managed care entity may discriminate against the application of any properly credentialed physician licensed to practice in New York State regardless of board certification status.  MSSNY will urge the New York State Department of Health and the New York State Health Maintenance Organization Council to support the MSSNY Managed Care Policy provision which are advanced in the interest of:  (1)  Continued quality patient care through sustained physician/patient relationships;  (2)  Equity through the elimination of demeaning, discriminatory, and prejudicial physician enrollment practices and will communicate these principles to all managed care systems doing business in New York State.  (HOD 1994-259; Reaffirmed HOD 1996-270, HOD 1997-222 & HOD 2003-100; Reaffirmed HOD 2013)

165.998           Point of Service Provision in Managed Care Programs

MSSNY supports legislation to require all managed care organizations to offer enrollees the option of purchasing coverage for medical care and services provided out-of-network or out-of-plan, and that such option be affordable and provide reasonable payment in order to allow enrollees to seek care outside managed care organization if so desired. (HOD 1994-64; Reaffirmed HOD 1996-58; Reaffirmed HOD 2014; Reaffirmed HOD 2016-60)

165.999           Regionalized Emergency Care Exemption  SUNSET HOD 2014

170.000           MANDATORY MEDICAID MANAGED CARE:

170.998           Medicaid Reform:  (Council March 9, 1995; SUNSET HOD 2015)

170.999           HIV Care in Mandatory Medicaid Managed Care:
                        (Council March 9, 1995; SUNSET HOD 2015)

175.000      MEDICAID: (See also Drugs and Medications, 75.000; Health Insurance Coverage, 120.000, Medicare, 195.000; Professional Medical Conduct, 250.000; Reimbursement, 265.000)

175.969           Medicaid and Child Health-Plus Renewals

The Medical Society of the State of New York (MSSNY) will work with the New York State Department of Health Office of Health Insurance Programs to establish policy that the insureds in Medicaid and Child Health Plus programs be contacted about the status of their insurance renewals and initial applications via their preferred method of communication, including but not limited to mail, e-mail, text and telephone. (HOD 2016-257)

 

175.970           Reinstate Partial Medicare Part B Coinsurance Payments

The Medical Society of the State of New York will continue to advocate for legislation which would restore New York State Medicaid coinsurance payments for patients insured by both Medicare and Medicaid and work with physicians and patient advocacy groups across the State to identify and bring to the attention of policymakers access issues affecting patients as a result of the elimination of Medicaid coinsurance payments for these dually eligible patients. 

The MSSNY delegation to the AMA House of Delegates will introduce a resolution calling upon the AMA to support federal legislation which would require coverage of the coinsurance payments for patients insured by both Medicare and Medicaid. (HOD 2016-64 & 65)

175.971           Acne Medication Coverage

The Medical Society of the State of New York (MSSNY) will support a change by New York State Medicaid to cover Retin A and similar topical acne medication sfor the treatment of acne.  (HOD 2015-250) 

175.972           OPMC Inform Physicians of Untended Consequences

Utilizing legislative, regulatory or other relief against the Office of Medicaid Inspector General, the Medical Society of the State of New York will seek a prohibition from removing a physician from the State Medicaid program solely on the basis that the physician entered into a consent order with the Board of Professional Medical Conduct. (HOD 2014-100) 

175.973           Equal Pay for Equal Medical Tasks

MSSNY reaffirms Policy 175.992 and will advocate for equal pay for equal medical tasks performed by equally qualified physicians regardless of the setting in which said task is performed. (HOD 2013-262)

175.974:          Short Acting Opioid Preauthorization

MSSNY will seek immediate action by New York State Medicaid to cease and desist from requiring a prior authorization on all short acting opioid pain medications for persons who have been on them for 120 days or longer, and to require at least 90 days’ notice of the enforcement of any such change in prior authorization requirements to allow for public comment and discussion. (HOD 2013-71)

175.975:          Medicaid Participation

MSSNY will continue to communicate with legislators, regulators and the media that efforts to expand health insurance coverage will not enhance timely quality care for patients unless steps are taken to assure the viability of physician practices to provide this needed care, and will continue to advocate for increased fees for providing care to Medicaid patients. (HOD 2013-65)

175.976           Mandated Medicaid Managed Care Programs

The Medical Society of the State of New York will encourage the State Assembly, Senate and Governor to:

(a) maintain current funding levels for providers, and assure that the cost of high quality nursing home care is adequately reflected in managed care rates and

(b) assure that Managed Long Term Care plan rates are established to meet wage parity or living wage requirements, and the increased risk that managed care plans are being asked to assume;

(c) assure that Long Term Home Health Care Programs are allowed to contract with a Managed Long Term Care Plan, to continue providing cost effective services that help chronically ill older adults and the disabled; and

(d) assure that the legislative bodies and executive herein mentioned vote for and sign into law the Independent Senior Housing Freedom of Choice Act (A.7309/S,4319), assuring that seniors living in congregate housing have the right to receive health care services that they would be able to obtain living in their own homes. (HOD 2012-107)

175.977           Mandate Single Formulary for All Medicaid Managed Care Programs and Participating
                         Carriers

The Medical Society of the State of New York will seek passage of state legislation and/or state regulation that a single formulary be mandated for all Medicaid managed care programs and participating insurance carriers. (HOD 2012-108)

175.978           Changes to Medicaid Patients Formulary

The Medical Society of the State of New York will seek legislation urging that the New York State Department of Health regulate HMO’s affiliated with Medicaid to “grandfather” drugs for Medicaid recipients who are already on medications and not require physicians to recertify these patients and change the longstanding prescriptions of these patients to conform to the HMO’s formulary. (HOD 2012-109)

175.979           Consequences of Involuntary Termination of Medicaid Participation:

MSSNY will work with the New York State Office of Professional Medical Conduct (OPMC), the New York State Office of Medicaid Inspector General (OMIG), The Joint Commission, the Healthcare Association of New York State (HANYS) and the Greater New York Hospital Association (GNYHA) to remedy the situation where disciplined physicians are allowed by OPMC to retain their medical licenses but are effectively relieved of any ability to treat their patients because of the regulatory cascade imposed by OMIG, hospitals and third party payers.  (HOD 2010-69)

175.980           Physicians as Medicaid Providers While in Supervised Recovery:

MSSNY will:

  1. request that the New York State Office of Professional Conduct (OPMC) and the New York State Office of the Medicaid Inspector General (OMIG) should work together cooperatively to permit physicians who are participating in a program of rehabilitation that includes practicing only in a monitored setting to maintain enrollment as a participating provider in the New York State Medicaid Program; and
  1. urge the New York State OMIG to recognize the plan of rehabilitation developed by the OPMC and Committee for Physician Health to permit physicians to return to the practice of medicine in a monitored setting and reinstate such physicians in the New York State Medicaid Program. (HOD 2009-111)

175.981           Promotion of Cost Savings for New York State:

MSSNY will study and explore ways that physicians can contribute ideas to our elected officials on ways to reduce the cost of health care to Medicaid without negatively impacting the quality of care or the physician-patient relationship, and communicate these ideas to its membership and the State of New York in an effort to help the state reduce its budget deficit.  (HOD 2009-99)

175.982           Medicaid Utilization Thresholds:

MSSNY will draft legislation to eliminate the necessity for physicians to submit separate utilization threshold requests prior to billing and attempt to secure sponsors for this legislation in the majority party of each house of the New York State Legislature and lobby actively to get this legislation introduced and passed in this legislative session.  (HOD 2009-98)

175.983           CPT Coding:

MSSNY will (a) draft legislation to require that the Medicaid program limit itself to standard Current Procedural Terminology (CPT) coding and standard billing forms and will attempt to secure sponsors for this legislation in the majority party of each house of the New York State Legislature; and (b) actively lobby to get this legislation introduced and passed in this legislative session.  (HOD 2009-97)

175.984           Reconsideration of the Current Medicaid Process

MSSNY will contact the newly-elected New York State Governor to:  (1) reconsider the hassles associated with the current process which are impediments to physician participation; and  (2) work with MSSNY in an effort to alleviate these impediments.  (Council 1/25/07)

175.985           Cost Effective Support for Medicaid Prenatal and Perinatal Services in Economically
                         Distressed Communities and Hospitals
:

The Medical Society of the State of New York will advocate for increased Medicaid rates, including prenatal and perinatal services that will allow for a sustainable infrastructure in underserved economically distressed areas.  (HOD 2006-155; Reaffirmed HOD 2016)

175.986           Identification of Medicaid Applicants:  Sunset HOD 2011

175.987           Medicaid as a Secondary Payer:

MSSNY will work with Medicare and Medicaid to create an automatic claim crossover system.  (HOD 2000-284; Reaffirmed HOD 2009-101)

175.988           New York State Department of Health Office of Medicaid Management Medicaid Fee
                         Increase
:

MSSNY and all of its component county medical societies will work together to affect ongoing changes in Medicaid fee schedules to make it a program more attractive to physicians, ultimately improving patient care.  (HOD 2000-64; Reaffirmed Council 6/3/04; Reaffirmed HOD 2014)

175.989           Expanding Scope of Commission on Medicaid:  SUNSET HOD 2014

175.990           Standing Orders:

Since (a) the Medicaid Program does not currently recognize a standing orders protocol which is widely accepted by other insurers and (b) it becomes inefficient and burdensome for physicians to provide original signatures on all laboratory test requisitions, MSSNY will urge the Office of Medicaid Management of the NYS Department of Health to:

  • Eliminate the requirement for original physician signatures, except the first signature, on each laboratory test requisition and allow standing orders for such tests involving chronic patient conditions (which may include, but not be limited to, diabetes (Glucose, Hemoglobin A1C/Glycohemoglobin), chemotherapy (CBC, Platelets), heart conditions (Prothrombin Time, Digoxin) substance abuse monitoring by a licensed treatment facility, any other condition deemed chronic in the reasonable judgment of a physician, etc.);
  • Allow the initial standing order containing an original physician signature to be valid for up to six months, after which time it must be renewed;
  • Enable physicians to designate staff members to sign the laboratory test requisitions on their behalf so long as the physicians formally acknowledge ultimate responsibility for the ordered tests;
  • Develop a similar protocol for electronically ordered laboratory tests
  • Interact the MSSNY, the Advisor on Practice Parameters Partnership and the NYS Clinical Laboratory Association (NYSCLA) to develop a listing of acceptable chronic conditions for the application of standing orders;
  • Interact with MSSNY and NYSCLA to develop an appropriate mechanism for the implementation of a standing orders protocol for laboratory test requisitions. (Council 2/4/98; Reaffirmed HOD 2014)

175.991           Public Health Mandate Funding:

Fee schedules for immunizations under public funding mechanisms such as Medicaid should be modified to include additional reimbursement to help defray physicians’ expenditures for compliance with State and City mandates which increase physicians’ operating costs.  (HOD 1997-268; Reaffirmed HOD 2014)

175.992           Site of Service Differential Payment Policy:

MSSNY reaffirms its position calling for the elimination of the highly objectionable Medicaid site of service differential payment policy for similar services provided in physicians’ offices as compared to hospital settings; particularly as the state-proposed Medicaid Managed Care Demonstration unfolds.  (Council 12/19/96; Reaffirmed HOD 2013; Reaffirmed HOD 2014)

175.993           Nine-Tier Reimbursement Structure for HIV Care:  SUNSET HOD 2014

175.994           Emergency Care Exemption Under a Regionalized SystemSUNSET HOD 2014

175.995           Funding for Medicaid Services

MSSNY has urged the Governor of the State of New York not to impose co-payments on Medicaid services, including nursing and therapy visits, paraprofessional services, prescriptions, and clinic visits.  In addition, MSSNY has urged the Governor to:  (1)  Retain the existing Medicaid personal care program;  (2)  Retain Medicaid payments to hospitals for patients receiving alternative level of care services; and  (3)  Not to freeze Medicaid reimbursement rates for home health care providers.  (HOD 1993-106; Reaffirmed HOD 2014)

175.996           “Pill Mill” Centers

MSSNY is seeking regulatory or statutory reform mandating that physicians affiliated with Medicaid “Pill Mill” Centers where there is undisputed evidence of Medicaid abuse be subject to an expedited license review and suspension as may be required by the appropriate agencies.  MSSNY is seeking to ensure that suspension of any physician’s license be based on direct and verifiable identification of the clinic(s) in question by the appropriate enforcement and investigative agencies and established community organizations, and not solely upon indirect and tangential criteria.  Such unacceptable criteria would include, but not be limited to, Medical Management Information Services (MIS) computerized billing records or superficial and unreliable “spot check” site visits productive of only anecdotal and ultimately inadmissible evidence as gathered by the funding agency of the Medical Assistance Program.  (Council 1/19/92; Reaffirmed HOD 2014)

175.997           Utilization and Audits

MSSNY is working with the New York State Department of Social Services and the New York State Department of Health to establish protocols against inappropriate utilization of Medicaid services and commensurate expenditures and to address the needs for:  (1)  Clear utilization of services parameters for dissemination to the physician community to guide physicians in the provision of health care under the Medical Assistance Program;  (2)  Development of more palatable and equitable methodologies to ensure appropriateness in audit investigations through mutually agreeable physician peer review activities and any disputes arising from such a peer review process.  (Council 12/19/92; Reaffirmed HOD 2014)

175.998           Fraud and Abuse Audit Control Activities

MSSNY is cognizant of the realities surrounding health insurance audit and utilization review activities to ensure justifiable expenditures of private or public funds for claimed medical services.  The Society is, nevertheless, deeply concerned by reports of inappropriate and inequitable Medicaid fraud and abuse investigations in New York State.

MSSNY asserts that any such fraud and abuse investigations motivated by established recoupment targets and bonus incentives by investigating state and federal entities is highly unethical, immoral, and contrary to the principles of fairness that are inherent in the American administrative and judicial system, and that have come to be rightfully expected by the medical community and the public at large.  In acknowledging that not all individuals seek to fulfill the highest aspirations of their particular professions, MSSNY believes that any such individuals in medical practice who subscribe to substandard principles of medicine and ethics in interacting with health insurance programs should be treated accordingly.  However, since MSSNY is confident that such practitioners comprise a decided minority of the state’s medical community, the Society logically expects the New York State Department of Social Services (NYSDSS) Fraud and Abuse/Audit Control Divisions, the New York State Attorney General’s Office, and the Office of the Inspector General to conduct legitimate Medicaid fraud and abuse investigation in an ethical and moral manner that ensures: (1)  Equitable and meaningful due process for those medical professionals whose services are under review or investigation;  (2)  Appropriate classification of Medicaid audits so that cases basically involving the following are not unduly labeled as fraudulent activities and, thus, pursued accordingly:  (a)  Lack of adequate documentation of services;  (b)  Simple billing irregularities; or  (c)  Other billing errors  (3)  Physician safeguards against occurrences of unwarranted prosecutions by investigating agencies through:  (a)  Utilization of medical experts to corroborate substandard medical practices and justify Medicaid investigations;  (b)  Provision of pertinent guidelines to physicians for proper conformance with Medicaid requirements;  (4)  Retention of sufficient physician participation in the Medicaid program to guarantee access to quality health care for medically needy recipient  (5)  Physician immunity against harassment and victimization by overzealous reviewers to the detriment of their well-being, community standing, and professional careers; with such reviewers being answerable for their unwarranted actions;  (6)  Physician immunity against undue harassment and pursuit by reviewers on the basis of state budgetary constraints or bureaucratically devised recoupment targets and bonus plan incentives;  (7)  Physician entitlement to reasonable compensation by the investigating state or federal agencies for legal costs incurred by exonerated practitioners for compelled involvement in arbitrary fraud and abuse or audit control activities.  In summary, it is the position of the Medical Society of the State of New York that no medical practitioner in the State of New York be subjected to the traumatic, intimidating and career-threatening activities of state and federal agencies, or any other health insurance entities, unless there is absolute and unimpeachable evidence of serious wrongdoing to warrant such focused pursuit.  (Council 1/31/91; Reaffirmed HOD 2014)

175.999           Medicaid – Title XIX Recipients:

The position of the Medical Society of the State of New York is that all Title XIX (Medicaid) recipients must have equal access to high-quality health care along with freedom of choice as to the source from which they receive such care.  This quality care should be delivered in an efficient manner by appropriately recognized and varying alternative mechanisms of medical care delivery.  Reimbursement for medical service rendered to Title XIX (Medicaid) patients must be based on a realistic fee pattern, in keeping with current economic realities and with the physician mode of practice.  Such fee patterns must be subject to periodic adjustments in the same manner as are all other recognized alternative mechanisms of medical care delivery.  Further, there should be a:  (1)  Return of Medicaid patients to the offices of practicing physicians by revising the New York State Medicaid fee schedule to provide usual and customary fees, or to implement a realistically higher fixed fee schedule.  (2)  Well developed peer review system, administered by physicians at the local level and providing for an adequate appeals mechanism through physician ombudsmen.  (3)  Development of a program that would provide incentives to physicians for locating in undeserved areas.  (4)  Unification of administrative and fiscal Medicaid responsibilities within a single Department at the State level.  (Council 4/22/82; Reaffirmed Council 6/3/04; Reaffirmed HOD 2014) 

180.000           MEDICAL DATA: (See also Acquired Immunodeficiency Syndrome (AIDS), 15.000)

180.980           SHIN-NY Connectivity 

The Medical Society of the State of New York will work with the New York eHealth Collaborative and the State Health Information Network – New York (SHIN-NY) to make sure that physicians do not have to pay any of the costs associated with connecting to, accessing or downloading data from the SHIN-NY network.

The Medical Society of the State of New York will oppose any state requirement or mandate to participate in the SHIN-NY as a condition of physician licensure. (HOD 2014-104) 

180.981           Correct Record Access

MSSNY supports action to assure that the imbedded costs of EHR technology, interoperability and additional administrative expenses associated with patient record access are added separately to the rate of payment currently received by the physician from the patient’s health payer.  In order to govern privacy and security of record transfer through the SHIN-NY, the State of New York should promote patient record access in accordance with rules developed through the Statewide Collaboration Process (SCP) which are delineated in the document entitled “Privacy and Security Policies and Procedures for Qualified Entities and their Participants in New York State, Version 3.0. (HOD 2014-106)

180.982           Charges for Copies of Medical Records

The Medical Society of the State of New York, working with other health care stakeholders, will advocate for a higher charge for copies of paper medical records which is related to the actual cost of reproduction.  The Medical Society of the State of New York will publish educational articles in its News of New York and eNEWS concerning the limitations of its ability to advocate for increases for the charge for copies of medical records. (HOD 2013-265, referred to, amended, adopted by Council 11/7/2013)

180.983:          Clear, Informed Consent Regarding Release of Medical Records

MSSNY will seek legislation, regulation or other appropriate means to assure that insurance companies obtain informed consent from patients that contains clear, concise and easy to understand wording; provides a detailed explanation of exactly how the information will be used; and notifies the signing party/parties that they can limit the scope of their consent. MSSNY will also seek to assure that, when insurers request medical records for a patient, they clearly state the intended use for their records and provide a copy of such request to the patient. (HOD 2013-68)

180.984        Privacy in Electronic Health Records

MSSNY endorses the recommendations of the Tiger Team of the National Health Information Policy Committee and supports their implementation by the State Department of Health, the New York eHealthCollaborative and all health information exchanges operating in the State of New York.  (HOD 2011-100)

180.985        Insurance Company Requests for Medical Records:

MSSNY will:

Seek legislation/regulation which requires that when insurance carriers request copies of medical records:

  • They allow at least 30 days for physicians to forward the records to the requestor;
  • There be a clear identification as to the reason for requesting the medical records;
  • Physicians be notified as to the outcome of the medical record review;

4)         A reasonable cap be placed on the number of records an insurance carrier can

request per patient;

5)         They follow the guidelines of the Recovery Audit Contractors (RACs) Summary of

Additional Documentation Limits as listed below:

Sole Practitioner:  10 medical records per 45 days per NPI

Partnership (2-5 individuals):  20 medical records per 45 days per NPI

Group (6-15 individuals):  30 medical records per 45 days per NPI

Large Group (16+ individuals):  50 medical records per 45 days per NPI;

6)         Requiring the managed care organization to render, in advance, a per-page fee,  pursuant to Public Health Law Section 18.

Reaffirm and actively pursue legislation in accordance with MSSNY Policies 180.988, 180.989, 180.992, 180.995.

Ensure that the drafted legislation include language that clarifies the physician’s ability to charge and collect for any/all postage costs.  (HOD 2010-257)

180.986           Methodology for Efficiency/Quality Indicator Data Collection and Analysis:

MSSNY will seek legislation and/or regulation that (1) permits patient data to be excluded from calculations utilized to develop physician profiles where medical advice and patient noncompliance are clearly documented, and such noncompliance has an adverse effect on a physician’s “quality,” “efficiency” and/or other similar rating; and (2) limits physician profiling data to the time period that the doctor-patient relationship existed.  (HOD 2010-94)

180.987        Social Security Form Completion:

MSSNY to seek legislation that increases the cost of completing this form to an inflation adjusted rate.  (HOD 2008-259)

180.988        Charges for Copies of Medical Records:

MSSNY will seek changes in state law to allow physicians to charge $2 per page for the first 15 pages and $1 per page thereafter, for photocopies of records requested for purposes unrelated to ongoing patient care and to allow other charges for mailing costs.  (HOD 03-59; Reaffirmed HOD 2010-257)

180.989        Realistic Time Frame to Comply with Requests for the Release of Medical
Records:

In an attempt to minimize any accusations for professional misconduct for failure to comply within a reasonable period of time, with requests for copies of medical records, MSSNY will aggressively pursue modification to Section 18 of the New York State Public Health Law which would redefine the “reasonable period of time” which physicians have to comply with requests for copies of medical records from its current definition of 10 days to a more realistic 30 days.  (HOD 2002-55; Reaffirmed HOD 2010-257)

180.990           FBI Raids:

MSSNY will take all necessary steps to ensure that government investigators not be permitted to remove records of patients from a physician’s office without copies being made prior to removal.

MSSNY’s position is that if patient records are seized and there is no provision made for copying of records at Government expense, copies must be made on side and left for the affected practitioners’ use in ongoing care of their patients.

State and Federal legislation must be sought which would provide immunity for physicians from any physicians from any suit or administrative proceedings where it can be shown that absence of the patient records contributed to an alleged negligent act or where the patient records seized contain information relevant to defending against an alleged negligent act.

MSSNY will seek passage of State and Federal legislation that would ensure that FBI investigations regarding physicians should be done in a matter that is sensitive to the health of patients and the viability of the medical practice under investigation, and that physicians not be required to pay any fees to receive copies of their patient records which have been seized by the FBI.  (HOD 2000-73; Reaffirmed HOD 2014)

180.991           Privacy and Confidentiality:

MSSNY will seek legislative/regulatory relief to prevent insurance companies and other managed care organizations from selling, trading, transmitting, or in any way communicating, individually identifiable health information to third parties.  Such legislative/regulatory relief should include a provision that patients be permitted to opt to provide individually identifiable information to third parties.  (HOD 2000-69; Reaffirmed HOD 2014)

180.992           Increase Fees for Medical Records Reproduction:

MSSNY will seek legislation to a) increase the amount annually by the previous year’s Consumer Price Index (CPI) that physicians can charge to reproduce copies of medical records in order to reflect inflation and the higher cost of living endured by physicians in New York; and b) to allow physicians to charge a search and retrieval fee of $15.00 plus $1.00 per page and that both fees be increased annually by an amount equal to the previous year’s CPI.  (HOD 2000-53; Reaffirmed HOD 1905-86; Reaffirmed HOD 2010-257)

180.993           Privacy of Medical Records:  SUNSET HOD 2014

180.994           Confidentiality of Patient and Physician Data:

MSSNY will continue to take whatever measures appropriate to discourage insurance companies and other health care agencies from publishing social security numbers and tax identification numbers whether it is stored, transmitted, or disposed of, in paper, electronic, or other media, and will become a strong proponent in efforts that may be underway to protect the confidentiality of patient and physician information whether it is stored, transmitted, or disposed of, in paper, electronic, or other media.  (HOD 1998-88; Reaffirmed HOD 2014)

180.995           Compensation for Providing a Patient’s Medical Record:

MSSNY will seek legislation to amend the New York State Public Health Law 17 and 18 to include language that would call for a charge of $1.00 per page for copies of patient information requested by a patient for use to facilitate the patient’s health care; and such legislation should include a provision that when copies are requested by other parties or for other purposes, the provider may impose a fee of up to $50.00 for search and retrieval, one dollar per page for paper copies, and two dollars per page for microfilm copies.  (HOD 1998-66; Reaffirmed HOD 2010-257)

180.996           Access to Medical Records  by Insurance CompaniesSUNSET HOD 2014

180.997           Privacy of Medical Records:

MSSNY supports the enactment of legislation to preserve patient privacy that includes the following:

(1)  that HMOs as well as other financial or insurance organizations obtaining medical information preserve this information in such a manner that only personnel under the authority of a physician (MD or DO) have the right to peruse the medical information and that records be kept of those who do access any medical records indicating the purpose for which it was accessed and the person, time and date when it was accessed.

(2)  that consent for release of information be limited to particular purposes.

(3)  that information used to determine medical necessity for payment be covered by the rules established above.  This would ensure that decisions regarding such necessity for payment would be subject only to medical rather than lay review.

(4)  that penalties established as a result of these evaluations be assessed in terms of gross revenues to prevent the larger entities from being able to violate the rules since the penalties might not affect them in any significant degree.

(5)  that repeated violations could result in loss of ability to conduct business in the health care field.

(6)  that violations by the supervising medical personnel be subject to professional sanctions and that repeated violations by personnel being supervised who disregard their organization’s and supervisor’s rules regarding confidentiality be subject to criminal as well as civil penalties.  (Council 10/24/96; Reaffirmed HOD 2015)

180.998           Medical Data Confidentiality

MSSNY formally recognizes the importance of safeguarding the confidentiality of patients’ records and, to this end, strongly supports appropriate legislation to protect this confidentiality regardless of form (paper, electronic, etc.) and prevent unauthorized persons from having access to sensitive, personally identifiable health data.  (HOD 1996-51; Reaffirmed HOD 2010-257)

180.999           Amendment of NYS Public Health Law 17 and 18

In order to adequately compensate a provider relative to the office time and resources expended for retrieval, inspection, copying and delivery of a patient’s medical records, MSSNY will seek legislation to amend Section 18 of the Public Health Law accordingly.(HOD 1996-91; Reaffirmed HOD 1997-65; Reaffirmed HOD 2010-95; Reaffirmed HOD 2011-118)

185.000          MEDICAL EXAMINER SYSTEM:

185.997           Recognition of Autopsies as an Educational Tool:

Because autopsies are valuable, indicated, necessary and in the public interest, MSNNY take the position that autopsies be encouraged for use as an educational tool; that treating physicians be notified of their patients’ autopsy results; and trained in the communication skills necessary to effectively obtain autopsy consent.  (HOD 2006-154; Reaffirmed HOD 2016)

185.998           Autopsies Performed by Medical Examiner

MSSNY will seek appropriate changes in New York State legislation and/or regulations to mandate the Coroner or Medical Examiner to release a copy of his autopsy findings to the attending physician and/or the hospital QA Committee in which the patient has expired.  (HOD 95-105; Reaffirmed HOD 1999-82; Reaffirmed HOD 2014)

185.999           Forensic MedicineSUNSET HOD 2014

190.000          MEDICAL MALPRACTICE / LIABILITY: 

190.988           Medical Malpractice Reform to Medical Injury Compensation (No-Fault)

MSSNY will continue to examine the feasibility of a No-Fault system for adjudicating medical liability claims and support such a proposal if there is demonstrable evidence that it would significantly reduce the cost of medical liability insurance coverage.  (HOD 2016-62; substitute resolution adopted Council Nov 3, 2016)

190.989           Clinical Practice Guidelines as Safe Harbors

The Medical Society of the State of New York will seek legislation to create a demonstration project which establishes use of evidence-based clinical guidelines developed by the appropriate specialty medical society as a safe harbor in any subsequent medical liability litigation which may arise. HOD 2016-116) 

190.990           NYS Medical Malpractice Insurance Market Undergoing Upheaval

The Medical Society of the State of New York will actively monitor and regularly communicate with the Department of Financial Services to ascertain the financial status of the various medical malpractice insurance companies operating in New York State; and it will continue to regularly update its members regarding the financial status of these insurers as well as the benefits of obtaining medical liability insurance coverage from a licensed New York insurer, including information regarding coverage for claims from the existing State guarantee fund in the event that a medical liability insurer becomes insolvent. (HOD 2016-69)

190.991           Restoring Liability Limits

The Medical Society of the State of New York will seek legislation to restore limits on physician liability to those individuals with whom there is an established physician-patient relationship; and in conjunction with its General Counsel continue to educate physicians regarding the consequences of the Davis v. South Nassau case which extends to third parties with no patient-physician relationship the right to sue such physician. (HOD 2016-63)

190.992           Medical Liability Insurance Education for Employed Physicians

The Medical Society of the State of New York working with MLMIC will facilitate the development of voluntary learning materials which will educate physicians regarding medical liability coverage needs associated with practicing medicine in New York State.   (HOD 2014-50) 

190.993           Lawsuit Against Expert Witness:

MSSNY will inform its membership of developments regarding legal actions brought by physicians against expert witnesses who have provided scientifically unsupportable testimony.  (HOD 2010-70)

190.994           Expert Witness Testimony in Medical Liability Cases:

MSSNY will develop educational resources which will assist physicians and specialty societies in learning about and recognizing the potential professional misconduct ramifications in providing inaccurate, scientifically unsupportable testimony while acting in the capacity of an expert witness in medical liability cases; and that MSSNY seek legislation to create a new category of professional misconduct for physicians who provide scientifically unsupportable expert witness testimony.  (HOD 2006-58; Reaffirmed HOD 2016)

190.995           Certifying Doctors for Malpractice Lawsuits

MSSNY adopts as policy that a physician who provides certification to a malpractice lawsuit in a certificate of merit should be board certified in the same specialty in the field called into question and licensed to practice in New York State; that a physician who provides certification to a malpractice lawsuit be required to sign a formal certification statement, and that their identity and credentials be clearly noted on this statement; and that these certifying statements be provided to the Court and to the physician who is sued so they can be verified.  (HOD 2005-95; Reaffirmed HOD 2015)

190.996           Amendments to the “Certificate of Merit” in Medical Liability Cases:

MSSNY will seek legislation which would provide that physicians who provide consultation to attorneys for purposes of executing the certificate of merit required in medical malpractice actions (CPLR, Section 3012-a) and who routinely, arbitrarily and falsely assert that a basis for such medical malpractice actions exist, shall be guilty of unprofessional conduct and shall be subject to all appropriate disciplinary penalties pursuant to the Public Health Law.  (HOD 1999-86; Reaffirmed HOD 2014)

190.997           Expert Witness Disclosure:

MSSNY supports legislation which would require the disclosure and pre-trial deposition of expert witnesses in medical liability cases.  (HOD 1998-85; Reaffirmed HOD 2014)

190.998           Certificate of Merit in Liability Cases:

It is MSSNY’s position that (a) a plaintiff’s attorney, when initiating a medial liability action, certify that he or she has consulted with a physician licensed to practice in New York State who has reviewed the relevant medical records, and that said physician is of the opinion that there were departures from good medical practice that caused injury to the patient; (b) that it is solely the responsibility of the plaintiff’s attorney to select the physician consultant commensurate with the above requirements; and (c) that the name of the consulting physician be made available.  (HOD 1998-73; Reaffirmed HOD 2014)

190.999           Reinstatement of Panel System

MSSNY will seek the reinstatement of the medical malpractice panel system which was eliminated in the 1991 legislative session. (1992 State Legislation Program; Reaffirmed HOD 2014)

195.000            MEDICARE: (See also Drug Dispensing, 70.000; Drugs and Medications, 75.000; Health Insurance Coverage, 120.000; Health System Reform, 130.000; Medicaid, 175.000; Peer Review, 225.000) 

195.923           CMS Revalidation of Medicare Billing Privileges

The Medical Society of the State of New York (MSSNY) will advocate that the Centers for Medicare and Medicaid Services (CMS) adopt the practice of sending revalidation notices to physicians using certified mail with return receipt, thus ensuring that such notices are actually sent by CMS and received by the physician; and that the New York delegation to the American Medical Association submit this resolution to the AMA House of Delegates Annual 2016 Meeting urging similar advocacy by the American Medical Association. (HOD 2016-269) 

195.924           Statute of Limitations for Medicare and RAC “Lookbacks”

The Medical Society of the State of New York (MSSNY) will ask the AMA to work with Medicare to reduce the “Lookback” period to be no longer than the length of time allowed to submit a claim for consideration. (HOD 2016-267) 

195.925           Medicare Advantage Plans and Delayed Claim Payments

Due to System Issues

The Medical Society of the State of New York (MSSNY) will urge the Centers for Medicare and Medicaid Services (CMS) to create specific, concrete guidelines applicable to any Medicare Advantage Plan (MAP) which has a “transition” of its system, or update of its claims processing system that could harm physician practices financially.

Any such guidelines from the Centers for Medicare and Medicaid Services (CMS) will impose punitive penalties (including payment of interest on delayed claim payments, and additional corrective actions), when an insurer’s “transition” of its system, and/or update of its claims-processing system, has led to (A) significantly delayed claim payments beyond the 30 days required by most contracts with Medicare Advantage Plans (MAPs); (B) improper adjudication of previously paid claims; and/or (C) improper denials followed by overpayment recoveries

As part of CMS’s punitive penalties and corrective actions, The Centers for Medicare and Medicaid Services (CMS), will require that any Medicare Advantage Plan (MAP) which has modified its system or updated its claim processing system should establish special service units, dedicated to resolving disputes and paying properly whenever the MAP’s system changes have led to (A) significantly delayed claim payments; (B) improper adjudication of previously paid claims; and/or (C) improper denials and then subsequent overpayment recoveries.  (HOD 2016-266) 

 

195.926           Inclusion of Disclaimer with Advertised Products

The Medical Society of the State of New York will seek legislation requiring inclusion of a clearly defined “disclaimer” identifying Medicare’s policy about “Reasonable Useful Lifetime” (RUL), (which ranges from 5 years to a lifetime benefit), in television and print commercial advertisements which claim to provide Durable Medical Equipment (DME) (e.g., back braces) with minimal or no out-of-pocket costs to Medicare beneficiaries, so that beneficiaries may make an informed and intelligent decision prior to ordering any “free” products. (HOD 2016-210) 

195.927           Support Tax Policies That Encourage Work by Older Americans

The Medical Society of the State of New York will request that the American Medical Association seek legislation to stop the practice by the federal government of deducting Medicare Part B coverage costs from the Social Security checks of retirees, as well as from salaries individuals may earn after they draw on social security benefits. (HOD 2016-207 adopted with title change)

195.928           Point of Care Availability for Blood Glucose Testing

The Medical Society of the State of New York will call on the AMA to work with Centers for Medicare and Medicaid in order to maintain the CLIA exempt status of point of care glucose testing.  (HOD 2014-252)

195.929           CMS “Two Midnight” Policy

The Medical Society of the State of New York will ask the AMA to demand that the Centers for Medicare and Medicaid educate the public and produce documents that outline the potential negative financial consequences of the “two midnight” policy. (HOD 2014-255)

195.930           Medicare Advantage Terminations Due to the Affordable Healthcare Act (ACA)

The Medical Society of the State of New York supports the information contained in the proposed rule by CMS, and supported by Congress, which states that Medicare Advantage Organizations notify their respective CMS Regional Account Managers no less than 90 (ninety) days prior to the effective date of planned termination(s) and MSSNY also supports CMS’ belief that their approach and expectations described in the proposed rule will promote a more structured, efficient process that will minimize confusion and disruption for Medicare Advantage Organizations, enrollee care, providers and CMS. (HOD 2014-256)

195.931           Application of Debt Collection Improvement Act of 1996

The Medical Society of New York will urge the American Medical Association to advocate for changes to the Debt Collection Improvement Act of 1996 so that CMS will be exempt from having to report to the Department of Treasury an outstanding debt arising from a Medicare/Medicaid overpayment when such original overpayment is $25 or less. (HOD 2014-63) 

195.932:          Medicare’s Non-Existent Relationship to Usual and Customary

MSSNY takes the position that there is no relationship between the Medicare fee schedule and Usual & Customary Fees, and requests that the MSSNY delegation to the AMA introduce a similar resolution at the next meeting of the AMA House of Delegates. (HOD 2013-253)

195.933:          Extrapolation by Medicare Recovery Audit Contractors (RACs)

MSSNY will urge the American Medical Association to petition the Centers for Medicare and Medicaid Services (CMS) to amend CMS’s rules governing the use of extrapolation in the Recovery Audit Contractor (RAC) audit process, so that the amended CMS rules conform to Section 1893 of the Social Security Act – Subsection (f) (3) – Limitation on Use of Extrapolation. MSSNY will insist that the amended rules state that when a RAC initially contacts a physician, the RAC is not permitted to use extrapolation to determine overpayment amounts to be recovered from that physician by recoupment, offset, or otherwise, unless (as per Section 1893 of the Social Security Act) the Secretary of Health and Human Services has already determined, before the RAC audit, either that (a) previous, routine pre– or post–payment audits of the physician’s claims by the Medicare Administrative Contractor have found a sustained or high level of previous payment errors; or that (b) documented educational intervention has failed to correct those payment errors. (HOD 2013-251)

195.934:          Unfunded Mandates Under the Medicare Program

MSSNY will 1) petition the New York Congressional delegation to urge the Centers for Medicare and Medicaid Services (CMS) to include in its proposed and final rule process, a cost–benefit analysis – using accepted actuarial and accounting standards – for any proposed or final mandate that would require physicians to incur costs; and will urge CMS to allow physicians and/or physician groups to claim an exemption if the cost–benefit analysis shows that compliance would cause significant financial hardship, or if the analysis shows that compliance would not be cost effective for the practice. (HOD 2013-250)

195.935           Prevention of Access to Care Crisis—SGR Fix

MSSNY will continue its efforts to work with the federation of medicine, including the American Medical Association, to advocate that Congress assures continued access to quality care for seniors by supporting legislation that would repeal the Independent Payment Advisory Board (IPAB) and reaffirms policy 195.970. (HOD 2012-61) 

195.936           Medicare Denial of Diagnosis Pre-Op for Testing

The Medical Society of the State of New York will work with National Government Services (NGS) Medicare to clarify the local coverage determination with regard to Medicare coverage of diagnostic services required in advance of any operative procedure. (HOD 2012-262) 

195.937           Medicare Re-Determination Online

The Medical Society of the State of New York (MSSNY) will request that the Centers for Medicare and Medicaid Services (CMS) and National Government Services (NGS) ,  study the feasibility of and the practical steps needed to implement, a secure technology that would allow physicians to file formal Re–Determination Requests (or Appeals) online.

The Medical Society of the State of New York (MSSNY) will urge the Centers for Medicare and Medicaid Services (CMS) to provide all physicians with access to technology a secure log-on function on the NGS website which would allow them to file formal Re–Determination Requests. (HOD 2012-263)

195.938           Abuse of Medicare as Secondary Payer

The Medical Society of the State of New York will educate its membership regarding proper billing protocols for other liability matters in Medicare Secondary Payer situations. (HOD 2012-264)

195.939           Primary/Secondary Insurance Billing Training Manual

The Medical Society of the State of New York will expand its  “Medicare as Secondary Payer” member training manual to reflect the many new complexities of the third–party insurance billing environment,  including:

  • new governmental and/or contractually determined billing rules,
  • new physician participation options,
  • broader overview of primary/secondary payment and billing policy (both governmental and contractually determined), and
  • a specific focus on the rights that physicians enjoy, and the limits with which they must comply, with regard to (1) the submission of claims to governmental and private insurers and (2) the balance billing of private or managed care patients. (HOD 2012-265

195.940           United Healthcare Mosaic Medicare Advantage Plan

The Medical Society of the State of New York will work with the American Medical Association to petition the Centers for Medicare and Medicaid Services to take all appropriate action with reference to the blatant disregard of Medicare Program regulations by United Healthcare, which through its Mosaic Medicare Advantage Plan, is requiring their panel physicians speak a particular language as a condition of present and continued participation.

The Medical Society of the State of New York will stress to CMS that there is no mandate that a physician in a Medicare Advantage Plan speak a particular language but only that they abide by the Medicare Managed Care Manual Chapter 4 Section 110.1, which states that they “ensure that all services, both clinical and non-clinical, are provided in a culturally competent manner and are accessible to all members, including those with limited English proficiency, limited reading skills, hearing incapacity, or those with diverse cultural and ethnic backgrounds.

The Medical Society of the State of New York will also advise the Centers for Medicare and Medicaid Services that their Regional and Central Office staff were contacted in regard to this issue and have stated in writing that the regulations cited in Chapter 4 Section 110.1 do, indeed, apply to United Healthcare and the Mosaic Plan but stating that it is their “belief” that they are in compliance with this section is a subjective statement to say the least.

The Medical Society of the State of New York must insist that this issue be addressed by the Office of the Secretary of the Department of Health and Human Services as contact with the component offices of CMS has identified a pattern whereby these entities have effectively abdicated their responsibility to enforce the directives in the Medicare Managed Care Manual.

The Medical Society of the State of New York will urge the CMS to require United Healthcare to withdraw its amendment mandating panel physicians speak a particular language and, in the event that these efforts are not successful, file a complaint with the federal Office of Civil Rights as this language requirement is perceived as racist and discriminatory in its intent. (HOD 2012-267)

195.941           Opposition to CMS 10-Year Overpayment Lookback

The Medical Society of the State of New York will strongly voice its opposition to the Notice of Proposed Rule Making (NPRM) published in the February 16, 2012 Federal Register by the comment deadline of April 16, 2012 and support the AMA in making a strong argument to CMS in opposition to this NPRM.  (Council 3/19/2012) 

195.942          Procedures Where MACs Notify Physicians

MSSNY will petition the Centers for Medicare & Medicaid Services to allow and appropriately budget Medicare Administrative Contractors (MACs) to expand their electronic mail notification procedures to include personalized e-mail alerts to physician practices that are candidates for Revalidation of their Enrollment information, so as to substantially decrease the volume of telephone calls and correspondence to the MAC service areas and help preclude the unnecessary revocation of physicians’ Medicare billing privileges.  (HOD 2011-258)

195.943         The Need for a Resource Explaining Medicare Remittance Denials:

MSSNY will work with National Government Services (NGS) Medicare to compile a user friendly document that will aid physicians in rectifying disputed claims.  (HOD 2011-257)

195.944        Reprocessing Claims Affected by the Patient Protection and Affordable Care Act and by
                      2010 Medicare Physician Fee Schedule Changes:

MSSNY will urge the Centers for Medicare and Medicaid (CMS) to continue to automatically adjudicate any and all claims that were inappropriately recompensed due to the significant tweaking of the Medicare Physician Fee Schedule during the first five (5) months of 2010.  Also, the NY Delegation will ask the American Medical Association at its Annual Meeting to urge CMS to automatically adjudicate Medicare claims similarly situated on a nationwide basis.  (HOD 2011-256)

195.945           NGS Systems Issues:

MSSNY should warn the Centers for Medicare & Medicaid Services (CMS) that in increasing instances, claims processed by the Multi-Carrier System are being denied, suspended or otherwise not paid due to technical errors by the System (e.g., the System may fail to properly read appropriate ICD-9 diagnosis codes, or may fail to calculate appropriate time frames for frequency screens), which have nothing to do with the way the physician submitted the claim.  Also, MSSNY will petition CMS to set up a dedicated unit or contact at the Multi-Carrier System site, to respond to reports from the county and state medical societies and the specialty societies about erroneous claim denials due to technical errors by the System, and to quickly resolve these error reports. (HOD 2011-255)

195.946           Provider Enrollment Chain Ownership System (PECOS) Penalty Phase:

MSSNY will continue to urge the Centers for Medicare and Medicaid Services (CMS) to postpone the initiation of any penalty phase regarding PECOS enrollment until such time as the Medicare contractors no longer have a backlog in their processing of the enrollment applications.  (HOD 2011-254)

195.947           National Government Services Should Re-open Its Local Coverage Determinations Web
                         Page
:

MSSNY will urge the Centers for Medicare and Medicaid Services to reestablish and fund the Local Coverage Determinations (LCDs) web page at the local Medicare Administrative Contractor (MAC) level and continue to work toward a more user-friendly and accessible LCD online resource.  (HOD 2010-254)

195.948           Reform of the Medicare Geographic Practice Cost Index (GPCI) System

MSSNY will:

(1) advocate with the Centers for Medicare and Medicaid Services (CMS) and with the New York State Congressional Delegation for increases in physician fees in the Upstate New York Medicare Physician GPCI system that will benefit the communities and physicians of Upstate New York without adversely impacting other areas of the state;

(2) have its President appoint a committee to study and report on reform options for the Medicare Physician GPCI system that will not have an adverse impact on other areas of the state; and

(3) continue advocating to the New York Congressional Delegation for elimination of the flawed Sustainable Growth Rate (SGR) methodology and for a meaningful increase in Medicare reimbursement that is consistent with increases in practice cost.  (HOD 2010-50)

195.949           National Government Services:

MSSNY will:

(1) work with National Government Services (NGS) to find and identify which physician practices continue to bill NGS via paper claims;

(2) work at assisting member physician practices that file paper claims to move forward toward electronic billing; and

(3) assist small member physician practices with being in a better position to afford HIPAA compliance. (Council 9/17/09)

195.950           National Government Services:

MSSNY will:

  1. continue to interact with National Government Services (NGS), while continuing to apprise the Centers for Medicare & Medicaid Services (CMS), the American Medical Association (AMA) and federal legislative officials regarding intolerable denials and delays in physician payments;
  2. b) urge CMS to provide fiscal support to NGS enabling NGS to have staff review paper claims rejected by the optical scanner and make appropriate improvements, to eliminate many of the denied claims;
  3. c) seek federal legislation to require that interest payment on Medicare physician claims be based upon 100% of the Medicare allowed amount since delays in payment adversely impact the collection of coinsurance;
  4. d) seek federal legislation which would impose a monetary penalty upon Medicare carriers, in addition to the interest payments, for failure to process and pay claims consistent with the current Medicare payment floors (13 days for electronic submission and 29 for paper claims);
  5. e) transmit a similar resolution to the American Medical Association seeking passage of federal regulation and/or legislation to accomplish the sentiments expressed in this resolution;
  6. f) take any action necessary – legal, regulatory, or litigation – to rectify the intolerable delays in physician payments due to National Government Services (NGS) denials and delays;
  1. g) contact other state societies serviced by NGS to explore working jointly with them to resolve problems with NGS;
  2. h) seek from CMS a requirement that NGS provide a service representative that has the authority to adjudicate claims and can be contacted by telephone for every physician that submits claims (either paper or electronically); and
  3. i) request that a person, committee or mechanism be set up to oversee the operation of the NGS and that the continuation of the NGS contract be reviewed periodically and predicated upon the quality or effectiveness of NGS operation. (HOD 2009-255)

195.951           Medicare Claims Processing Problems Under National Government Services:

MSSNY will educate its members about Medicare’s Advance Payment process, including submission requirements, restrictions and offset procedures that will affect future Medicare payments made when all corrections have been addressed and will work with the Centers for Medicare & Medicaid Services to improve patient access problems created for Medicare beneficiaries by reducing this and many other operational problems created for Medicare physicians.  (HOD 2009-254)

195.952           Medicare Physician Payments:

MSSNY will ask the American Medical Association to interact with the Centers for Medicare & Medicaid Services (CMS) to ensure that any plan that CMS contracts with to provide a Medicare Advantage product be mandated to adhere to Medicare’s National Coverage Determinations (NCDs) and Local Coverage Determinations for their service areas.  (HOD 2009-253)

195.953           Internet-Based Instant Messaging Program for Medicare Customer Care Contact Centers:

MSSNY will:

-urge the Centers for Medicare & Medicaid Services (CMS) to allocate a budget item allowing National Government Services (NGS – the Medicare Administrative Contractor for New York) to provide, through the NGS Customer Care Contact Center, an Internet-based instant messaging or live chat feature that would enable physicians to communicate with NGS in real time;

-stress to CMS that such a service would help physicians discuss and resolve critical questions related to claims processing, education, and other pressing issues;

-alert CMS and NGS to the existing precedent, namely, the “Live Chat” system now used by Empire Blue Cross Blue Shield/Wellpoint; and

-urge NGS to work with Empire to implement a similar system.  (HOD 2009-252)

195.954           On-Site PC-ACE and Electronic Claims Training for Physicians:

MSSNY will petition the Centers for Medicare & Medicaid Services (CMS) and National Government Services (NGS) to identify and contact paper-claim submitters who might benefit from submitting claims electronically, using such software as Medicare’s PC-ACE Pro-32 package.  Also, MSSNY to urge CMS to include in its NGS budget a separate item for the development and implementation of a PC-ACE Pro-32 training program, to be provided on-site (in physicians’ offices), whereby physicians and their staff could learn to submit their claims electronically via the PC-ACE software. (HOD 2009-251)

195.955           Issues Handled by Medicare Telephone Reopening Units:

MSSNY will assist National Government Services (NGS) with the communication to MSSNY’s membership via the News of New York, the EVPgram, and the MSSNY website about the formal list of specific issues that can and cannot be reopened via the Medicare Administrative Contractor’s (MAC) telephone reopening unit (TRU).  (HOD 2009-250)

195.956           Medicare Contractor-Based PQRI:

MSSNY urge the Centers for Medicare & Medicaid Services (CMS) to (a) intensify its Physician Quality Reporting Initiative (PQRI) training efforts via sessions at the Medicare Administrative Contractor (MAC) level, rather than via national conference calls at the CMS level; (b) require the MACs to set up specialty-specific seminars, addressing the PQRI measures that are unique to each specialty area; and (c) integrate a mechanism to provide timely feedback during the course of the reporting year to physicians.  (HOD 2009-96)

195.957           Centers for Medicare and Medicaid Services’ Deadlines for Implementation of Changes,
                         e.g. National Provider Identifier:

MSSNY submit a formal protest to the Centers for Medicare and Medicaid Services (CMS) urging CMS not to commit to hard deadlines for changes to be implemented; rather CMS should work toward a transition that does not adversely impact physician cash flow caused by systems problems that result in denied/rejected claims. (Council 3/03/08)

195.958           Support for Critical Opposition to the Impending Medicare Fee Reduction:

MSSNY, in partnership with the American Medical Association, to emergently and aggressively advocate to eliminate the current 10.6% reduction in Medicare scheduled payments for July 1, 2008, with a remedy similar to that proposed in Senator Stabenow’s Senate Bill S2785, as well as to lobby Congress for reform of the SGR formula to reflect the true cost of the delivery of quality patient care.  (HOD 2008-266)

195.959           Home Infusion of Antibiotics:

MSSNY will ask the American Medical Association to work with the Centers for Medicare and Medicaid Services (CMS) to develop a coordinated system among the various Medicare plans to ensure an expedited, seamless process for provision of home infusion of antibiotics to reduce the need of the patient to remain in the hospital unnecessarily.  (HOD 2008-254)

195.960           Medicare Private Contracting Opt-Out Renewal Requirement:

MSSNY will request that the American Medical Association draft legislation to amend Section 1802 of the Social Security Act, as amended by Section 4507 of the Balanced Budget Act of 1997 as it relates to Private Contracting under Medicare, to rescind the two-year opt-out renewal requirement for private contracts between physicians and Medicare beneficiaries.  Also, the language in this proposed amendment would provide that private contracts will be deemed to remain in effect indefinitely unless and until the physician rescinds the private contracts and rejoins the Medicare Program. (HOD 2008-253)

195.961           Medicare Carrier Processing of Claims Involving Retired, Archived, or End Dated Local
                        Coverage Determinations
:

MSSNY will:

-seek formal written clarification from the Centers for Medicare & Medicaid Services (CMS) regarding the CMS policy on local coverage determinations (LCDs) that have been retired, archived or end dated;

-seek clarification of CMS’s routine statement regarding particular LCDs that have been retired, archived or end dated, in which CMS states, (1) all local policy rules, requirements and limitations within these LCDs will no longer be applied on a prepay basis but, as with any billed service, will be subject to post pay review, and (2) all Centers for Medicare & Medicaid Services national policy rules, requirements and limitations remain in effect;

-seek CMS’s confirmation that the above statement means that claims involving already retired LCDs should go through to payment when they are initially submitted (prepay); and

-request that CMS require Medicare carriers to issue formal instructions to physicians regarding CMS’s policy regarding the payment of claims involving LCDs that have been retired, archived or end dated.  (HOD 2008-252)

195.962           Undue and Burdensome Regulations Inflicted by Medicare Part D Pharmacy Benefit
                         Plans
:

MSSNY will work with the Medicare Part D pharmacy benefit plans to

(1) devise and expedite a process so that physicians may, in the proper practice of medicine, prescribe for doses and durations that are in the best interest of their patients and supported by the medical literature; and

(2) allow patients who demonstrate significant therapeutic benefit and stability on their current therapeutic regimes to continue such regimes as a covered benefit under their current Medicare Part D carrier without interference or interruption.  (HOD 2008-251)

195.963           Difficulty Filing Medicare Claims:

MSSNY will urge the American Medical Association to work with the Centers for Medicare & Medicaid Services (CMS) toward achieving an orderly transition to the National Provider Identifier number that does not adversely affect physician cash flow by asking CMS to provide claims adjudication services that are more physician-friendly and more open to communication to physicians and carriers.  (HOD 2008-250)

195.964           Consumer Rights for Durable Medical Equipment:

MSSNY will request that the American Medical Association conduct a study regarding greater transparency and increased choices to patients in meeting their durable medical equipment needs. (HOD 2008-163)

195.965           Deadlines for Implementation of Changes:

MSSNY will submit a formal protest to the Centers for Medicare and Medicaid Services (CMS) urging CMS not to commit to hard deadlines for changes to be implemented; rather CMS should work toward a transition that does not adversely impact physician cash flow caused by systems problems that result in denied/rejected claims.  (Council 3/3/08)

195.966           Interaction by the Medicare Part D Carriers with the Physician Community re Drug
                         Dosages:

MSSNY will:

(1)        advise the Regional Office of the Centers for Medicare and Medicaid Services (CMS) that physicians are very concerned with the manner in which the Medicare Part D carriers are interacting with the physician community regarding drug dosages.  Physicians find utilization review activities that demand the completion of cumbersome forms and submission of chart notes unwarranted and believe that these activities interfere with the practice of medicine; and

(2)        urge the CMS Regional Office to re-evaluate the manner in which their Medicare Part D carriers interact with the physician community and instruct their Medicare Part D carriers that the dosage levels provided to the geriatric community for a variety of prescribed drugs often differ from the standard of FDA approved indications and/or therapeutic dosages.  (Council 3/3/08)

195.967           Postponement of National Provider Identifier (NPI) Implementation Date:

In view of the Centers for Medicare & Medicaid Services (CMS) failure to appropriately address data dissemination concerns relating to the security and protection of physician issued National Provider Identifier (NPI) numbers, MSSNY to request that the May 23, 2007 NPI implementation date be postponed, at least until CMS has appropriately developed and published their Data Dissemination Policy in the Federal Register.  (HOD 2007-257)

195.968           Medicare Opt Out Physicians and Secondary Insurers:  

In conjunction with the New York State Insurance Department, MSSNY will:

(1) draft legislation to develop and implement a mechanism to:  a) require secondary insurers to identify Medicare opt out situations;  b) allow physicians and patients who have executed a Medicare Opt Out agreement (yet still participate with the secondary private or managed care insurer) to have their claims processed correctly by making the secondary insurer primary as Medicare is no longer the primary insurer and no Medicare explanation of benefits exists; and

(2) draft legislation to:  a) identify Medicare Opt Out situations; and b) include the requirement that the secondary insurer access the Medicare fee schedules posted on the carrier websites in order for the secondary insurer to calculate their payment responsibility in the event that present insurance law cannot be changed and the secondary insurer can reduce the benefit paid based on what Medicare would have covered.  (HOD 2007-250)

195.969           Herpes Zoster Vaccine and Medicare Payment:

MSSNY will encourage Medicare to pay for the herpes zoster vaccine and the service of providing it.  (HOD 2007-114)

195.970           Sustainable Growth Rate (SGR):

MSSNY continues its aggressive lobbying efforts to eliminate the flawed Medicare Sustainable Growth Rate (SGR) Formula and replace it with a system that more appropriately factors the annual increase in practice costs. (HOD 2007-50; Reaffirmed HOD 2012)

195.971           Holding Medicare Payments:
                       (Sunset HOD 2016)

195.972           Recovery Audit Contractor:
                       (Council 9/22/05; SUNSET HOD 2015)

195.973           Repeal of Section 306 of the Medicare Modernization Act:
                       (Council 3/14/05; SUNSET HOD 2015)

195.974           Medicare MCO’s, CMS Operational Policy Letter #46, and the Proposed Handover of the Medicare Program to Private and Managed Care InsurersSUNSET HOD 2014

195.975           Medicare and ‘Off-Label’ Uses of Drugs:

MSSNY opposes the imposition of any limitation, including under the new Medicare “Part D” drug benefit, on the “off-label” prescribing practices of physicians, whether by statute, regulation or operating practice of any private contractor administering such benefit.  (HOD 2004-67; Reaffirmed HOD 2014)

195.976           Low Molecular Weight Heparin:

MSSNY will advocate the interpretation of the BIPA 2000 provision for Medicare coverage of “drugs and biologicals which are not usually self-administered by the patient” as being inclusive of LMWH used in the short term outpatient treatment of venous thrombosis.

MSSNY will communicate this request to the New York State Carrier Advisory Committee.

MSSNY will submit a resolution to the House of Delegates of the American Medical Association supporting and advocating a directive by the Centers for Medicare and Medicaid Services to all fiscal intermediaries, mandating the aforementioned interpretation of BIPA 2000.  (HOD 2002-272; TABLED PENDING FURTHER INVESTIGATION HOD 2013)

195.977           Empire Medicare Services:  Physical Medicine and Rehabilitation:

MSSNY, through its Committee on Interspecialty agrees to do the following:

  1. a) Work with the Medicare Carrier Advisory Committee (CAC) to amend Medicare’s proposed policy on Physical Medicine and Rehabilitation so that there is greater practicality to the actual practice of physical therapy and rehabilitative medicine.

b) Request that the AMA CPT Editorial Panel revise the direct patient contact definition so that there is greater practicality to the actual practice of physical therapy and rehabilitative medicine.

  1. c) Recommend that the Medicare Carrier Advisory Committee change the Physical Medicine and Rehabilitation policy to state that all passive procedures (e.g. manual stretching, etc.) are to be under the direct one to one ratio of care, while active procedures (e.g. balance training exercises, etc.) may be delivered under the general supervision guidelines as enumerated in the Federal Register. The Committee also recommended the use of Procedure Code 97150 in those instances where the patient is performing active exercises.  (Council 7/19/01;         Reaffirmed HOD 2010

195.978           Removal of Benign Skin Lesions:  Sunset HOD 2011

195.979           The Treatment of Pain:  Sunset HOD 2011 

195.980           Prescription Drug Benefit for Seniors:  Sunset HOD 2011

195.981           Expansion of Medicare Coverage for Preventive Services:

MSSNY will recommend to HCFA, Congress and the President that screening for hypertension, vision and hearing, as well as counseling for tobacco cessation, physical activity and nutrition be included as covered preventive services under Medicare and that additional federal appropriations be made for these services.  (HOD 2001-262; Reaffirmed HOD 2011)

195.982           Elimination of $75.00 Charge for Purchase of Medicare E.D.E.N. Relay/Gold Software for
                          Electronic Billing:

SUNSET HOD 2014

195.983           Medicare “Fraud and Abuse”:

MSSNY will urge the appropriate federal and state agencies to acknowledge that the characterization of any billing errors as “fraud” to be libelous and offensive.

MSSNY objects to the heavy handed techniques of search and seizure, with guns drawn and without formal charges levied, as tactics of a totalitarian police state;

MSSNY will demand that Congressional inquiry address these concerns, which give the perception that the physicians are “GUILTY UNTIL PROVEN INNOCENT,” with open public hearings at the earliest opportunity.

MSSNY objects to and rejects “statistical analysis” that attempt to claim that a physician’s billing or practice is aberrant by use of flawed methodologies, and will advocate to stop the use and extrapolation of this data as “fraud and abuse.

MSSNY will seek legislation, in concert with the AMA, directing the Health Care Financing Administration (HCFA) to remove the notations of fraud reporting announcements from all mailings to Medicare beneficiaries in order to prevent erosion of the physician/patient relationship.  (HOD 2000-255; Reaffirmed HOD 2014)

195.984           Proposed CAC Policies:  SUNSET HOD 2014

195.985           Repealing Restrictions on Private Medicare Contracting

MSSNY will support and lobby on behalf of related bills HR 2497 (Representative Archer) and S.1194 (Senator Kyl), which would amend Title XVIII of the Social Security Act to clarify the right of physicians and other health care providers to enter into private contracts with Medicare beneficiaries for:  a) the provision of health services for which no payment is sought under the Medicare program; b) the right to privately contract with beneficiaries without physicians having to opt out of the program for two (2) years.  MSSNY will introduce a resolution to the 1999 Annual Meeting of the AMA House of Delegates calling for the Association to support and lobby on behalf of related bills HR 2497 and S.1194.  (HOD 1999-271; Reaffirmed HOD 2014)

195.986           System for Checking Eligibility of Patients in Medicare HMOsSUNSET HOD 2014

195.987           Opposition To Limitations on Medicare Contracts:

MSSNY will support corrective legislation concerning the Section 4507 of the Balanced Budget Act to allow Medicare beneficiaries to enter into private contracts for provision of medical care without any significant preconditions being imposed either on the patient or on those providing the care.  MSSNY will specifically seek to abolish the requirement that the physicians providing care under a private contract must forego participating in the Medicare program for two years.  (HOD 1998-261; Reaffirmed HOD 00-82; Reaffirmed HOD 2014)

195.988           Comparative Performance Reports (CPRs):  SUNSET HOD 2014

195.989           Physicians’ Appeals of Medicare Hearing:  SUNSET HOD 2014

195.990           Patient’s Choice In Continuing a Physician/Patient RelationshipSUNSET HOD 2014

195.991           Mandatory Enrollment of Medicare – Medicaid Patients in Managed Care Plans:

MSSNY strongly opposes mandatory enrollment of Medicare-Medicaid patients in managed care plans, and will actively use any available means to prevent forced enrollment and will bring this resolution before the next American Medical Association House of Delegates to be adopted as an official policy of the American Medical Association.  (HOD 1997-103; Reaffirmed HOD 2014)

195.992           Beneficiary Identification System  SUNSET HOD 2014

195.993           Durable Medical Equipment Providers, Prohibition of Solicitation of Patients:
                       SUNSET HOD 2014

195.994           Electronic Paper Claims:
                        SUNSET HOD 2014

195.995           Extrapolation Methodology in Medicare and Medicaid Postpayment Review:

MSSNY is:

(1)  Petitioning the AMA to urge HCFA to adopt a policy that Medicare carriers just provide data which justify the statistical validity of their findings when any extrapolation technique is used in a Medicare post-payment audit and review process prior to any request for return of monies paid to physicians;

(2)  Seeking statutory changes in the Medicare and Medicaid laws to prevent the application of the extrapolation methodology in order to ensure due process for physicians whose medical records and billing procedures are under review;

(3)  Educating physicians in concert with local county medical societies about the potential abuses by Medicare and Medicaid administrators in carrying out reviews, and identifying legal resources which can be called upon by individual physicians for legal assistance and/or defense in cases of alleged Medicare/Medicaid fraud and abuse or overpayment.  (HOD 1992-5 & 1992-76; Reaffirmed HOD 2014)

195.996           Medical Necessity Determinations

MSSNY is urging the Health Care Financing Administration to require Medicare carriers to provide physicians with the name and phone number of the physician responsible for making a determination as to the medical necessity in the initial letter of inquiry sent by the carriers. (Council 9/13/90; Reaffirmed 2009-259)

195.997           Fair Hearing:
                       SUNSET HOD 2013

195.998           Mandatory Acceptance of Medicare Assignment as a Condition of Licensure/Re-
                          licensure
:
                        SUNSET HOD 2013

195.999           Mandatory Acceptance of Medicare Assignment

MSSNY opposes mandatory assignment for payment for Medicare services.  (HOD 1983-45; HOD 1990-46; Reaffirmed HOD 2014)