January 2000
Government Relations
Practice Directorate
For more information: E-mail
The Senate health care reform bill permits only physicians to fully participate in internal and external review of services to the detriment of patients under the care of other health care professionals. Managed care reform conferees should accept the House-passed Norwood/Dingell bill language, which appropriately recognizes the role of non-physician providers during internal and external services? review.
THE PROBLEM. The Senate bill (S. 1344)?
- Patient Advocacy. Allows only physicians to advocate for and submit information on behalf of their patients during external appeal. Patients under the care of other health care professionals must proceed alone.
- Internal Review. Restricts medical necessity decisions to physicians only, even when other health care professionals are qualified to make these decisions.
- External Review. Denies qualified health care professionals from participating as external reviewers of services.
The "physician" references in the Senate bill are detrimental to patients under the care of non-physician health care professionals. Many patients receive services from non-physician providers with minimal or no physician participation in their care. Psychologists, for example, typically treat patients without any physician involvement. The Senate bill, permitting only physicians to advocate for and submit information on behalf of their patients during external review, denies these procedural rights to patients under the care of psychologists and other non-physician health care professionals.
The "physician" references are anti-competitive. Physicians and other health care professionals currently compete to provide and review health care services in the private market. Health plans should have the flexibility of having all qualified health professionals review services during internal and external review for the services that they provide.
While physicians should not be "second guessed" by those who are not qualified to make medical decisions, non-physician health care professionals should be permitted to participate in internal and external review decisions for the services that they are licensed or otherwise qualified to provide. Conversely, not all physicians are qualified to review the services of highly trained non-physician providers. A family physician is not qualified to review the diagnostic or psychotherapeutic services of a clinical psychologist. An internist is not qualified to review oral surgery provided by a dentist.
THE SOLUTION. The conferees should accept the House language, which?
- Patient Advocacy. Permits all treating health care professionals, not just physicians, to advocate for and submit information on behalf of their patients during external appeal.
- Internal Review. Allows physicians and other highly skilled non-physician health care professionals, such as dentists, to make medical necessity determinations. The House language should be amended to permit psychologists to review the mental health services, which they are uniquely qualified to provide.
- External Review. Allows physicians and other highly qualified health care professionals to participate in external review, while specifying that only physicians may review physician services.
