AMA to tackle claim denials based on specialty, audit equity

March 1, 2004



It's a problem: Some insurance companies are denying reimbursement based on a physician's specialty. An insurer, for example, may deny payment to a primary care physician who wrote a prescription for an antidepressant because that physician is not a psychiatrist.

To combat the problem, the American Medical Association approved a policy in December 2003 to discourage insurers from continuing the practice and to support "appropriate action" at the state and federal levels, according to American Medical News (1/5/04). The policy has the backing of many specialists, who believe that claim denials based on specialty restrict access to care. Moreover, some claim the denials put the practice of medicine in the hands of insurers, rather than physicians.

In addition, the AMA adopted a separate policy to push for legislation requiring insurers to refund for undercoding or balance it against any overcoding found during an audit. Just as insurers demand money back if overcoding is discovered, the AMA wants physicians to receive a refund for any excess due to undercoding.