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Unfair Health Plan Payment Policies

RESOLVED, that the North Carolina Medical Society supports appropriate remedies, including legislative or regulatory remedies, to address unfair payment policies that disadvantage physicians, and result in patient inconvenience and injustice. Such unfair payment policies include:

  • Demands for Refunds of “Overpayments,”
  • Payor Responsibility for Payment following Eligibility Verification,
  • Suspended Payments Pending Receipt of Coordination of Benefits (COB) Information from Patients,
  • Balance Billing for Services Later Not Deemed Medically Necessary or for Ineligible Patients,
  • Bundling and Automatic Downcoding,
  • Absence of Provision of Fee Schedule Information and Fee Schedule Updates,
  • Payor Refusals to Honor Assignments of Benefits,
  • Provision of Mandatory Clinical Guidelines to Physicians,
  • Absence of Opportunity for Provider Initiation of Grievances and Appeals,
  • Health Plan or Payor Communications which Give Providers a Negative Image,
  • Excessive Requests for Medical Records and Lack of Adherence to Principles or Patient Confidentiality,
  • Refusal to Permit Specialist Physicians to Act as a Direct Point of Entry for Patients with Diseases within their Area of Specialization; and be it further

RESOLVED, That the North Carolina Medical Society supports the use of an evaluation mechanism or “report card” on all third party payors measuring communications, medical review programs, payment efficiency and accuracy, and other attributes.

(Report K-2001, adopted as amended 11/11/01)
(revised, Report L2-2004, Item 40, adopted 11/14/2004)
(reaffirmed, Report I-2009, Item 2-38, adopted 11/01/2009) (reaffirmed, Reaffirmation Report-2014, Item 2, adopted 10/25/2014)