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Fairness Measures in Managed Care

RESOLVED, That the North Carolina Medical Society supports measures to assure fairness in the practice of managed care. Fairness measures for patients and physicians should address:

  • certification of managed care plans based on compliance with standards regarding access of enrollees to providers, disclosure of plan limitations, solvency, physician input into medical decision making, opportunity for physicians to apply to managed care panels, and assurance of patient confidentiality;
  • due process for physicians who are terminated from panels;
  • appropriateness of utilization review standards, including clinical relevance of screening criteria, and qualifications of physicians involved in utilization review;
  • opportunity for patients to select plans with a reasonable point of service option;
  • allowing any willing physician provider access to practice within any plan or plans of the provider’s choice; if the provider meets the criteria for all others in the provider’s scope of practice, and if the provider agrees to accept the terms of contract offered by the managed care organization; and
  • requiring annual public disclosure of the complete financial statement of the managed care organization to include annual revenues, expenditures by line items, salaries, bonuses and fringe benefits paid to officers, directors and stockholders of such organizations and public disclosure of the names of officers, directors and stockholders.

(Report AA-1994, adopted as amended 11/6/94)
(revised, Report L2-2004, Item 29, adopted 11/14/2004)
(reaffirmed, Report I-2009, Item 2-31, adopted 11/01/2009) (reaffirmed, Reaffirmation Report-2014, Item 11, adopted 10/25/2014)