Opposing Health Plans Restricting Medically Necessary Care (PDF)

Submitted by Dr. Sterling Ransone

WHEREAS, health plans have instituted a number of mechanisms to restrict medically necessary care
to patients including step therapy and prior authorization, and

WHEREAS, these cost-control mechanisms are used to limit prescription medications, therapies,
medical equipment, procedures, services and imaging, and

WHEREAS, step therapy is a cost-control process that many health plans use for prescriptions, and

WHEREAS, prior authorization is a health plan cost-control process many health plans use for
prescriptions, procedures, and services, and

WHEREAS, these processes require providers to obtain approval, which most often requires hours of
uncompensated physician and staff work, and

WHEREAS, despite the 2015 law passed in Virginia, physician practices are still experiencing
numerous problems with prior authorizations, and

WHEREAS, frequently health plans change their criteria for “medical necessity” with little to no notice
or explanation, and

WHEREAS, these mechanism cause interruption in the care of the patient and interferes in the doctorpatient relationship, therefore be it

RESOLVED, the Medical Society of Virginia opposes any health plan mechanism that interferes in
the timely delivery of medically necessary care, therefore be it further

RESOLVED, the Medical Society of Virginia supports requiring health plans to provide physicians with
real time access to covered benefits, the criteria for “medical necessity” and cost
information so that physicians and their patients may work together to choose the most
cost-effective medically appropriate treatment for patient care.

1 reply
  1. coastalfp
    coastalfp says:


    Well stated, Dr. Ransone.

    It is time to ratchet up the pressure on those that on a daily basis negatively impact the lives of patients and physicians.

    Mitchell B. Miller, MD

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