AAOS supports legislative efforts that will
ensure patient protections within health plans.
Few issues frustrate physicians more than prior
authorization, the process that requires physician offices to ask for
permission from a patient’s insurance company before prescribing certain
medications or performing medical procedures. The time spent by staff members,
physicians, and patients on persuading insurance companies to cover a procedure
is not only expensive, but also may detract from patient care. Prior
authorization has become the tool of choice for health insurers in denying
care, limiting utilization, and regulating the patient-physician relationship.
Health plans with high out-of-pocket expenses
and narrow insurance networks continue to grow in the Affordable Care Act (ACA)
market exchanges. As a result, balance billing for out-of-network providers has
become a major issue for regulators, the media, and physicians.
Patient protections are necessary to restore
the physician-patient relationship, preserve the patient's choice of physician,
and enhance access to specialty care. These protections include:
to medically necessary specialty care in-network.
ability to seek treatment out-of-network for a non-cost-prohibitive copayment.
prohibition on financial incentives that result in the withholding of care or
denial of a referral.
information provided to all enrollees and prospective enrollees that allow them
to make an informed choice about plan coverage.
A ban on
"gag" clauses which prohibit physicians from discussing with patients
their treatment options.