ACP: Governmental Affairs and Public Policy - ACP Urges NAIC Provide A Model Physician-Complaint Process

Advocacy

ACP Urges NAIC Provide A Model Physician-Complaint Process

April 14, 2004

Ernst Csiszar, President
National Association of Insurance Commissioners
2301 McGee Street
Suite 800
Kansas City, MO 64108-2662

Dear Commissioner Csiszar:

The American College of Physicians (ACP), the nation's largest medical specialty society, representing over 115,000 internists and medical students, recommends that the National Association of Insurance Commissioners (NAIC) provide state insurance departments a model electronic system for collecting physician complaints against health plans that fail to comply with state insurance prompt payment and other laws. We recommend that the model be based on the Texas Department of Insurance Physician/Provider Complaint Form process and/or other states that aggressively collect physician-specific grievances. A physician-specific complaint process would provide a mechanism for state insurance departments to assess the quality of health plan claim payment practices. A systematic mechanism to collect, filter and evaluate documentation of potential health plan non-compliance would improve the ability of state insurance departments to enforce their laws.

ACP is aware that NAIC tracks complaints that consumers file with state insurance departments and we commend NAIC for its efforts. We are especially encouraged by the existence of the NAIC-sponsored Uniform Regulation Through Technology (URTT) program and the Complaints Database Statistics (CDS) of 46 states' full or partial participation. We believe that a system that allows separate reporting of physician and other consumer complaints optimizes the insurance department ability to regulate health plans. We believe the CDS reporting mechanism could be easily modified or expanded for collecting and categorizing physician-specific complaints of health plan non-compliance. Operational since 1991 with over 1,300,000 closed consumer complaints providing data for analytical reports, trends and disposition; a modified or expanded CDS would be an effective resource in such an endeavor. Further, our recommended electronic, dual system would bring efficiencies as it is our understanding that not all of the current mechanisms permit on-line reporting, and the even the majority that do require that the consumer print the completed complaint and mail it to the investigating agency.

A physician-specific complaint process would increase physician awareness of the ability to report significant problems with health plans and minimize what we suspect is under-reporting of legitimate complaints. However, ACP wants to avoid deluging insurance departments with complaints and encourages physicians to report only legitimate complaints regarding health plan actions. We offer our members assistance in addressing their concerns with health plans, using a progressive process that begins with dealing directly with the health plan. As a concurrent or next step, working with the American Medical Association, we provide physicians with access to a complaint process that identifies payment delays and associated problems. We expect this process to solve clerical and other disparities prior to a need for regulatory agency intervention. We typically only recommend filing a formal complaint with the state insurance department if the plan is unresponsive to the physician's concerns.

Physician practices are accountable to health plans through post-payment review audits and other measures, in addition to being subject to State and Federal laws/regulations. Physician access to an electronic complaint process to report non-compliant health plans would give physicians in all states, some reciprocal regulatory assurances.

ACP is pleased that NAIC implemented the Insurance Regulatory Modernization Action Plan and included as its highest priority its Consumer Protection Action Plan. It is our belief that consumer protection is the highest priority and it begins with properly following health insurance contracts for beneficiaries and physicians written, approved and marketed under the authority of state insurance regulatory agencies.

NAIC adopted policies for external review procedures in 1999 but noted that, as recently as August 2003, not all state insurance departments had such requirements. Adding that, regardless of the existence of a law establishing an external review process, all state insurance departments are dedicated to the fair resolution of questions and complaints from consumers about insurance. A physician's ability to provide medical care is adversely affected when a health plan fails to deliver on its commitment.

ACP hopes that NAIC will accept our request to use existing electronic systems for collecting and identifying physician-specific complaints of health plan non-compliance, or offer alternative proposals for achieving this goal. Please contact Brett Baker, Senior Associate in the Department of Regulatory and Insurer Affairs by phone at (202) 261-4533 if you have questions.

Sincerely,

C. Anderson Hedberg, MD, FACP, Chair
Medical Service Committee