Patient Protection

AAOS supports legislative efforts that will ensure patient protections within health plans. 

Few issues frustrate physicians more than prior authorization, the process that requires physician offices to ask for permission from a patient’s insurance company before prescribing certain medications or performing medical procedures. The time spent by staff members, physicians, and patients on persuading insurance companies to cover a procedure is not only expensive, but also may detract from patient care. Prior authorization has become the tool of choice for health insurers in denying care, limiting utilization, and regulating the patient-physician relationship.

Health plans with high out-of-pocket expenses and narrow insurance networks continue to grow in the Affordable Care Act (ACA) market exchanges. As a result, balance billing for out-of-network providers has become a major issue for regulators, the media, and physicians.

Patient protections are necessary to restore the physician-patient relationship, preserve the patient's choice of physician, and enhance access to specialty care. These protections include:

  • Access to medically necessary specialty care in-network.

  • The ability to seek treatment out-of-network for a non-cost-prohibitive copayment.

  • A prohibition on financial incentives that result in the withholding of care or denial of a referral.

  • Comprehensive information provided to all enrollees and prospective enrollees that allow them to make an informed choice about plan coverage.

  • A ban on "gag" clauses which prohibit physicians from discussing with patients their treatment options.