Physician Consultation in Medical Policies

20.1 - Physician Consultation in Medical Policies (Rev. 24, 06-06-03) The MA organization must establish a formal mechanism to consult with the physicians who have agreed to provide services under the MA plan offered by the organization regarding the organization’s medical policy, quality assurance/improvement programs and medical management procedures and ensure that the following standards are met: 1. Practice guidelines and utilization management guidelines: • Are based on reasonable medical evidence or a consensus of health care professionals in the particular field; • Consider the needs of the enrolled population; • Are developed in consultation with contracting physicians; and • Are reviewed and updated periodically. 2. The guidelines are communicated to providers, and, as appropriate, to enrollees. 3 Decisions with respect to utilization management, enrollee education, coverage of services, and other areas in which the guidelines apply are consistent with the guidelines. An MA organization that operates an MA plan through subcontracted physician groups must provide that these policies apply equally to physicians within those subcontracted groups. (Source: 42 CFR 422.202(b) and (c).)