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AMA insurer code similar to health reform law's requirements

Publish date: AUG 01, 2010

NATIONAL REPORTS—The American Medical Assn. (AMA) released its "Health Insurer Code of Conduct Principles," which defines 10 standards AMA believes will ensure consistent corporate practices.

The organization sent letters to the chief executive officers of major insurers, including the Blue Cross Blue Shield Assn. Letters ask insurers for their "commitment to full transparency and accountability with respect to all of their clinical and administrative processes."

Issues addressed in the guidelines include: cancellation of coverage, medical spending, access to care, fair contracting, patient confidentiality, and administrative simplification. The standards are endorsed by 68 state and specialty medical societies, according to AMA.

More pressing, however, is the Patient Protection and Affordable Care Act (PPACA) and the specific operational changes it expects.

"The code echoes much of the requirements set forth in the PPACA law," says Lisa G. Han, partner, Squire, Sanders & Dempsey. "There are opportunities for greater collaboration between payers and providers under the healthcare reform law."

Han says that the medical community has a right to identify potential issues in the insurance industry, however most insurers already follow the code's specifications.

According to Kaiser Permanente Ohio spokesperson Renee DeLuca, her organization is aware of the code and has updated policies to reflect it.

The regulations provide guidance to employers and sponsors regarding the definition of a grandfathered health plan, as well as the changes that may and may not be made.

Innovative payers are starting to look differently at how they build their pharmacy network, using a bottom-up approach to network design.

A Kaiser Family Foundation survey reveals that 77% of enrollees with non-group coverage faced premium increases in the past year and "ever skimpier coverage."

Accountable care organizations have become a hot commodity since the Patient Protection and Affordable Care Act opened the door for health plans to contract through an ACO for commercial enrollees. The momentum of ACOs will likely increase.

One of the first visible payoffs of the Patient Protection and Affordable Care Act is the $250 rebate checks sent to thousands of seniors with high drug costs. Other strategies are built on questionable long-term outlooks.


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