Access to Services and Accountability for Decisions Regarding Their Utilization for Managed Care Patients in Long Term Care Facilities

Resolution L97
Becomes Policy September 1998

AMDA resolves that managed care organizations covering patient stays in long term care facilities, including subacute care admissions, should coordinate with the facility access for their patients to necessary and appropriate physician services, therapy and other professional services, pharmacy services, laboratory and other ancillary services and durable medical equipment. Such coordination should ensure that their covered patients have access to the same services and supplies which are provided to other residents of the facility, or services and supplies which are equivalent and not less convenient for the patient and facility to access; and

FURTHER RESOLVES, that prospective and concurrent utilization review decisions by a managed care organization or its agents which influence or may serve to influence medical decision making for any insured individual should be determined to the practice of medicine in each and every state of the United States. As such, all such utilization review determinations should be made pursuant to the authority and accountability of a physician licensed to practice medicine in the jurisdiction where the patient care occurs. In the cases of such utilization review decisions affecting residents of long term care and subacute care facilities, the physician responsible for the decision should be adequately qualified or informed in the fields of long term care medicine and subacute care.