confidentiality of provider and individual medical records must also be followed. (2) Health coverage plans should establish credentialing criteria to allow physicians within the plan's geographic service area to apply for credentials. Credentialing should be based on standards of quality with criteria and profiles available to physicians. (3) Health coverage plans should establish a mechanism under which physicians can provide input into insurer’s medical policies. (4) Health coverage plans should allow for physician to provide input regarding their participation in health coverage plans which includes, but is not limited to, the following: a. Permitting physicians to negotiate with insurers on the terms and conditions of their participation on provider panels. b. Disclosing all participation requirements and selective contracting criteria to physicians interested in entering into a contractual relationship. c. Establishing self-governing medical staffs similar, if not identical, to those in hospitals that function under the principles of self-governance. d. Establishing appropriate utilization review criteria which includes but is not limited to: (i) A model in which a medical director is responsible for all clinical decisions of the plan. (ii) Screening criteria, weighting elements, and computer algorithms used in the review be based on sound scientific principles, developed with physicians having an essential role;. (iii) Only a physician of the same specialty as the practitioner who provided a service should be permitted to recommend denial of coverage or payment. (iv) Provide to participating physicians the names and credentials of those who conduct medical necessity or appropriateness reviews.
213.04 Physician Contracts & Payment - Discounting of Cost of Care REAFFIRMED
The LSMS supports allowing hospitals and physicians and other healthcare providers to discount the cost of care to the uninsured and to those individuals who have purchased high deductible insurance plans as the physician or healthcare provider deems appropriate based on the patient’s economic conditions.
213.20 Physician Contracts & Payment – Bundled Payment Systems REAFFIRMED
The LSMS opposes mandatory bundling of reimbursement for episodes of care to hospitals that precludes independent billings by physicians.
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