Code of conduct needed for health insurers, too

The American Medical Association (AMA) is considering a national health insurer code of conduct, calling on the U.S. health insurance industry to adopt consistent practices regarding costs, business transparency and the physician-patient relationship.

While health care providers — physicians, nurses, hospitals — adhere to strict professional and medical codes, no similar protocols exist for insurers. And although regulated to some extent like many industries, health insurers have had no meaningful self-regulation — an important business practice and one that a code of conduct ensures.

This is important because health insurers are the primary bridge between physicians and their patients, between hospitals and physicians, and between patients and hospitals. Health insurers should provide easy access to necessary health care. But they often are an obstacle.

In my neurology practice, I often encounter situations that demonstrate the need for such a code of conduct. Recently, a patient whom I’d seen regularly presented with a new neurological problem that did not seem related to the chronic condition for which he is routinely followed. I requested a new diagnostic test and went through the usual procedure for a “precertification” for the test, required by the insurance carrier. The carrier denied it.

The patient then developed problems and went to the emergency room. After the patient was transferred to another facility, the neurological test I’d originally asked for was conducted and confirmed a brain tumor. What’s worse, the patient initially was given a different test in the ER that erroneously suggested the possibility of a stroke.

If the recommended test had been approved to begin with, the subsequent emergency room visit, transfer via ambulance and additional, more costly testing would have been avoided. The patient would have been admitted to the hospital and had a routine, rather than emergency, consultation and operation.

This may sound like an extreme example of a system not working, but this is not an uncommon scenario.

The AMA’s proposed code of conduct will lay out clear principles to be followed by health insurers, addressing medical and payment issues, monitoring and compliance frameworks, and restrictive practices that damage the physician-patient relationship.

It seeks to shine a light on any third party who influences the health care of a patient, ensuring that the physician provides that care — not a managed care company — and that no unauthorized changes are made without the knowledge of the physician and patient.

Health care reform has stepped onto the stage in Washington. Much debate will take place about what needs to be added and what needs to be fixed. Holding the health insurance industry accountable — to itself — is a strong starting point.

Dr. Christina Mayville is a neurologist in Macon.