310.000 UTILIZATION REVIEW

310.992           Utilization Review

The Medical Society of the State of New York will seek legislation/regulation that requires insurance companies, peer review organizations, Centers for Medicare and Medicaid Services, and others to use the review criteria that existed at the time that services were provided when making their determinations.  This resolution will be forwarded to the AMA.  (HOD 2018-60)

310.993           Low Cost Arbitration:  SUNSET HOD 2019

310.994           Use of Binding Arbitration:

MSSNY will seek a change to the law to permit binding arbitration clauses in contracts between physicians and patients.  (HOD 2006-61; Reaffirmed HOD 2016) 

310.995           Independent Medical Examiners:

MSSNY will legislation to create a pool of physicians in each specialty to act as Independent Medical Examiners (IMEs) for all third party payers doing business in New York State who request such a service in order to determine the need for further or continued medical treatment.

MSSNY will urge the Office of the Insurance Commissioner assign IMEs from the pool to conduct physical examinations and review medical records on a purely rotating basis so there is no bias in the selection of the IMEs; or, alternatively, select an independent organization, such as the Empire Foundation, to administer such an IME program with fees to be paid by the insurers.  (HOD 2000-280; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

310.996           Third-Party Payer Use of Unsubstantiated Demand and Refund Letters:

MSSNY will seek amendment to the New York State Insurance Law to address the issue of payer demand letters, and to reflect the following provisions:  1) the physician should have the right to due process, should have access to all pertinent carrier documents, and should have the right to review the post-payment audit sample with appropriate carrier personnel; 2)  in post-payment reviews, carriers should not retroactively apply new policy to old claims; 3)  where the amount in dispute exceeds $1,000, physicians should have the right to have an independent entity not employed by the third-party payer (such as a Peer Review Organization or the American Arbitration Association) review the results of the carrier’s post-payment review; and 4) third-party payers should not seek repayment through the claims offset process until the physician has exhausted all appeals, and until an accurate overpayment amount has been established.  (HOD 2000-279; Reaffirmed HOD 2010-259; Reaffirmed HOD 2020)

310.997           Arbitration in Cases of Third-Party Audits:

MSSNY will seek legislation or regulation for the development of an independent arbitration panel to handle requests for refunds by third-party payers arising from audits of physicians’ practices.  (HOD 1998-265; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

310.998           Third Party Audits of Physicians with Subsequent Billing of Physicians for Tests Deemed Inappropriate:

MSSNY will urge the appropriate state and federal regulatory agencies to regulate third party payers’ medical practice audits such that these audits focus on providing education and improving the quality of care, and not be used for financial or punitive activities.  MSSNY will work to ensure outcomes of all medical practice audit processes would be governed by rules of due process which will be available for all physicians who participate in third party audits. (HOD 1998-255; Reaffirmed HOD 2014; Reaffirmed HOD 2024)

310.999           Medical Director to be Required for all Third Party Payors: 

The Medical Society of the State of New York will seek whatever legislative or regulatory action is necessary to insure that all health insurance companies that are licensed in the State of New York and performing utilization review have a physician medical director who is licensed by the State of New York, who is accessible and identifiable to the treating physician; and will seek regulatory action which assures that plan medical directors are held accountable for their medical review determinations.  (HOD 1997-58; Reaffirmed HOD 2014; Reaffirmed HOD 2024)