Physician Decision-Making in Health Plans

THIRD-PARTY PAYORS

Physician Decision-Making in Health Plans

RESOLVED, That the North Carolina Medical Society opposes the preemption of treating physicians’ judgments by third party payors in responsibilities including, but not limited to, the following:

  • Selection of diagnostic tests that are appropriate;
  • When and to whom in-plan physician referral is indicated;
  • When and to whom out-of-plan physician referral is indicated;
  • When and with whom consultation is indicated;
  • When non-emergency hospitalization is indicated;
  • When hospitalization from the Emergency Department is indicated;
  • Choice of in-plan service sites for specific services (office, out-patient department, home care, etc.);
  • Hospital length of stay;
  • Frequency and length of hospital out-patient visits or care;
  • Use of out-of-formulary medications;
  • When and what surgery is indicated;
  • When termination of extraordinary heroic care is indicated;
  • Recommendations to patients for other treatment options, including non-covered care;
  • Scheduling of on-call coverage;
  • Terminating a physician/patient relationship;
  • Whether to work with and what responsibility should be delegated to mid level practitioners; and
  • Determination of the most appropriate treatment methodology.

(Resolution 12-1997, adopted as amended 11/16/97)
(revised, Report L2-2004, Item 47, adopted 11/14/2004)
(reaffirmed, Report I-2009, Item 2-30, adopted 11/01/2009) (reaffirmed, Reaffirmation Report-2014, Item 9, adopted 10/25/2014)

 
 

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