As part of its Utilization Management Policies and Procedures, Access 2 Health Care Physicians {A2HCP) requires practitioners, providers, and staff who make utilization decisions (as well as those who supervise them) to receive the statement below:
A2HCP's decisions for care are based only on medical appropriateness and plan coverage. Incentives are not offered for denials. A2HCP does not make decisions about hiring, promoting or terminating practitioners or other staff based on the likelihood, or on the perceived likelihood, that the practitioner or staff member supports, or tends to support, denial of benefits. A2HCP does not offer financial incentives designed to encourage decisions that result in underutilization.
Specifically, A2HCP asserts that:-
Decision- making is based only on appropriateness of care and service and existence of coverage.
A2HCP does not specifically reward practitioners or other individuals for issuing denials of coverage for service or care.
Financial incentives for UM decision-makers do not encourage decisions that result in underutilization.