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MEDICAL PRACTICE
STRATEGIES & ISSUES

“MEdICAl dIRECTORS. Simply because a physician is not
providing direct patient care does not mean that the physician is not
practicing medicine or obligated to adhere to the principles of med-
ical ethics. Whenever physicians employ professional knowledge
and values gained through medical training and practice, and in so
doing affect individual or group patient care, they are functioning
within the professional sphere of physicians and must uphold eth-
ical obligations. This is true not only if the physician is making de-
terminations of medical necessity or coverage, but also if the
physician is involved in developing a health plan’s general policies
that affect patient care, e.g., utilization guidelines”.
“MEdICAl NECESSITY. The determination of medical ne-
cessity is the practice of medicine; it is not a benefit determination.
Whether or not a proposed treatment is medically necessary should
be decided in a manner consistent with generally accepted stan-
dards of medical practice that a prudent physician would provide
to a patient for the purposes of preventing, diagnosing or treating
an illness, injury, disease or its symptoms. This is true even if the
physician making the medical necessity determination is making
those decisions on behalf of a managed care organization. That
physician must not permit financial mechanisms to interfere with
his/her determination as to whether a treatment is medically nec-
essary. Although the physician may take cost considerations into
account, the physician may not refuse to approve the medical ne-
cessity of a treatment simply based on cost, and must approve the
treatment if it is clearly more therapeutically effective than other
treatment options that may be covered under the plan, even if
those treatment options are less expensive than their more costly ing precertification or preauthorization based on medical necessity
counterpart”. as the practice of medicine; and include any denial of precertifica-
“UTIlIZATION REvIEW. The physician who performs tion or preauthorization of medical services based on a determina-
prospective and/or concurrent utilization review is obligated to re- tion of medical necessity as the practice of medicine”
view the request for treatment with the same standard of care as Pre-authorization was instituted by insurance companies saying
would be required by the profession in the community in which the they wanted to make sure physicians are not ordering unnecessary
patient is being treated”. services and tests when the patient does not need them. However,
the practice of medicine by physicians is sacrosanct in ensuring
Texas Medical Association has Policy 145.024 proper patient care.
regarding the same issue.
“Medical decision Makers licensed in Texas: The Texas Medical Please let TMA and AMA know about your hassle stories be-
Association will (1) support legislation that would amend the Texas cause they want to create momentum and they want to defend
Insurance Code to require utilization review agents to be supervised physician and patient rights and develop a comprehensive prior-
by physicians licensed to practice medicine in the State of Texas authorization bill.
and all denials of care based on medical necessity to be made by
physicians licensed to practice medicine in the State of Texas and Jayesh B Shah, MD is board certified in Internal Medicine and Undersea
in the same or similar specialty as the treating physician seeking au- and Hyperbaric medicine, is a member of the Board of Trustees of the Texas
thorization of medical care; and (2) work to amend the Medical Medical Association, and was the 2016 President of Bexar County Medical
Practice Act to clearly include the supervision of persons perform- Society.

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