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HE REVIEW COMMITTEE is established to help identify and cope with case situations in which the amount of the physician's fee has been influenced by the type and amount of insurance owned by the patient. (The Coordinating Committee and the Review Committee responsibilities are both assigned to the present Nassau County Medical Society Voluntary Health Insurance Committee).

A. Organization

The committee will be composed of representatives of the American Academy of General Practice and various medical specialties. Appointments should be made by the President of the Nassau County Medical Society for a three year period; one-third of the committee should be rotated each year. Reappointments may be made after a lapse of one year.

The committee shall meet as frequently as necessary depending on the volume of cases submitted for review but not more often than once a month.

B. Relationships

The Committee shall maintain liaison with the Grievance Committee and Board of Censors of the Nassau County Medical Society on cases where the judgment of the committee is disputed by the attending physician and the insuring organization has elected to submit the case to the Grievance Committee or Board of Censors for further action.

C. Functioning

In general the committee will function by reviewing cases submitted by the insuring organizations or policyholders. Cases will be submitted on the

basis of the information contained in attached Exhibit III "Review Committee Information Form" addressed to the chairman of the Review Committee at the Medical Society's offices. Medical Society lay personnel will assign identifying case numbers to the form and complete statement No. 14 (see form) before referring case to the Chairman. The Chairman will detach the lower section of the form and assign the case to a membc: of the committee for review at least seven to ten days prior to the meeting of the full committee. This preliminary review will be based on the information contained in the upper part of the form. The review may involve contact with the insurance organization for additional informa tion. The report based on this review (see reverse side of Exhibit III) will be submitted to the chairman on an anonymous basis with recommendation either for further consideration or no action.

The Chairman will then submit both sections of the form together with the reviewing physician's recommendation to the full committee for disposition.

It is understood that the insuring organization or policyholder will make a reasonable effort to discuss the disputed fee with the doctor before submitting the case to the Review Committee. The determination of the Review Committee will be accepted as the basis on which the insuring organization will discharge its liability in a specific case. If the individual physician refuses to accept the fee determined by the Review Committee, the insurance organization or policyholder will then have the option of presenting the case to the Grievance Committee and ultimately the Board of Censors if necessary.

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IS ANTICIPATED that the Nassau County Medical Society through the Coordinating Committee develop and circulate the following information to members of the Society:

(a) An announcement of the program and its objectives.

(b) Material which the physician might use to resist pressure from the patient to falsify claims information submitted to the insuring organization. This might include, (1) a brief pamphlet which would explain to the patient how the existence of this program avoids wasteful practices and encourages the most econmical and efficient use of his insurance dollar, and (2) a copy of the statute presently effective in New York State which makes it a misdemeanor to submit fraudulent

information to an insurance carrier (See Exhibit IV) and,

(c) Periodic reports on an anonymous case history basis illustrating typical problems encountered under the program and how they were resolved.

In view of the series of articles on inefficient use of hospital facilities and other alleged wasteful practices which recently appeared in the local press, it is suggested that the Coordinating Committee also consider the advisability of an announcement of the program and its objectives for publication in the press as a demonstration of medicine's awareness of the problem and our willingness to take effective steps to meet it, subject to approval of the Executive Committee and the Press Committee of the Nassau County Medical Society.