The new code can help insurers recommit to high professional standards, the AMA said. Fifteen years ago, the companies’ trade association adopted a “Philosophy of Care,” but since then, “the insurance industry’s record of compliance with its standards has been questionable.” Companies adopting the new code will “renew their commitment and earn the trust of patients and physicians,” the AMA said.
AMA President J. James Rohack said the code’s 10 principles will “help protect patients and physicians from questionable insurance practices by holding the health insurance industry accountable.”
Here is a summary of the 10 principles in the “Health Insurer Code of Conduct Principles.”
1. Cancelling policies due to preexisting conditions. Such actions must not apply to innocent mistakes and insurers must allow for outside review and not award bonuses to employees for finding reasons to deny coverage.
2. Setting premiums and out-of-pocket charges. A “substantial bulk” of the premium dollar must be spent on healthcare and companies must justify increases and report expenditures.
3. Making health care accessible. Services must be nearby and available to all enrollees.
4. Respecting enrollees and providers. Physicians must be allowed to talk freely with patients about care options.
5. Designating covered care. The insurer’s determination of what services will be covered must be based on what a “prudent physician” would provide, in accordance with generally accepted standards and appropriate for the particular patient.
6. Defining benefits. Coverage of drugs and other services must be “consistent with clinically appropriate medical guidelines.”
7. Eliminating complex requirements. Processes such as obtaining approvals for services must be simple.
8. Evaluating physicians. Evaluations used in physician profiling must focus on quality of care and not on reducing costs.
9. Complying with all laws. Insurers must comply with “the letter and spirit of the laws” and promote corporate integrity.
10. Processing claims. Insurers must pay claims in an accurate and timely manner.
Read the AMA’s release on insurance practices.
