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1 AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES

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4 Resolution: 118
5 (A-09)
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7Introduced by: Texas Delegation
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9Subject: Transparency of Preventative Care Services
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11Referred to: Reference Committee A
12 (Steve E. Larson, MD, Chair)
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15Whereas, Physician offices and our insured patients are uncertain of what is covered for
16preventive care services and recommended vaccines; and
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18Whereas, Important preventive care services and vaccines may be delayed or payment not
19made for completed services; therefore be it
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21RESOLVED, That our American Medical Association seek legislation requiring insurance
22companies to adopt standardized, readily accessible and understandable terminology spelling
23out coverage for preventive care services, including adequate payment for recommended
24vaccine products and services. (Directive to Take Action)
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26Fiscal Note: Implement accordingly at estimated staff cost of $1,188.
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28Received: 05/06/09
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 3 Resolution: 118 (A-09)
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1RELEVANT AMA POLICY
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3D-180.984 Payer Measures for Private and Public Health Insurance
4Our AMA will work with state medical associations, employer coalitions, physician billing
5services, and other appropriate groups to evaluate on an annual basis and recommend
6standards for "payer measures" for the insurance industry and government payers to be publicly
7reported for consumers that may include information such as: 1. Number of patients enrolled 2.
8Total company and individual plan revenue/expense and profit 3. Procedures covered and not
9covered by policy 4. Number of primary and specialist physicians 5. Number of denied claims
10(and %) a. Number denied based on "pre-existing condition" b. Number denied and later
11allowed c. Number denied for no reason 6. Waiting time for authorization of common procedures
127. Waiting time for authorization of advanced procedures 8.Waiting time for payment 9.
13Morbidity and mortality due to denied or delayed care 10. Number of appeals by customers or
14physicians 11. Number of successful appeals by customers or physicians 12. Number of
15consumer complaints 13. Number of government fines/sanctions 14. Use of economic profiling
16of physicians to limit physicians on panel 15. Use of quality measures approved by qualified
17specialty societies (Res. 703, I-06; Reaffirmation A-07; Reaffirmed in lieu of Res. 828, I-08)
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19D-180.985 Health Plan and Insurer Transparency
20Our AMA will: (1) continue to closely monitor any new "transparency" programs unveiled by
21health plans to determine the impact on physicians; (2) communicate to health plans, employers
22and patients our concerns about current "transparency" programs, and educate them about
23"true transparency"; and (3) continue to educate physicians about the complexities of claims
24adjudication and payment processes to enable them to more efficiently manage their practices.
25(BOT Rep. 19, A-06; Reaffirmation A-07)