Medical Pre-Certification and Utilization Review Activities

Subject:

Medical Pre-Certification and Utilization Review Activities

Request By:

Bryant D. Paris, Jr. Executive Secretary Board of Medical Examiners

Question:

Do medical pre-certification and utilization review activities constitute the practice of medicine under North Carolina law?

Conclusion:

No.

For purposes of this question, medical pre-certification and utilization review activities are reviews of the need for either the initiation of medical treatment for a patient or for the continuation of such treatment which are conducted by insurance companies, medical assistance programs or other third-party payors after an initial determination has been made that treatment should be initiated. When a determination is made that the treatment is not appropriate or not necessary, third-party payment is denied.

G.S. 90-18 provides, in part, that "[a]ny person shall be regarded as practicing medicine or surgery within the meaning of this Article who shall diagnose or attempt to diagnose, treat or attempt to treat, operate or attempt to operate on or prescribe for or administer to, or profess to treat any human ailment, physical or mental, or any physical injury to or deformity of another person . . ."

As a practical matter, a denial of third-party payment may have a direct impact upon the patient’s decision of whether to undergo the treatment. However, such denial does not prohibit the patient from seeking other funding sources or from seeking treatment without third-party benefits, and it does not prohibit the attending physician from providing the treatment. The decision to forego or to continue medical treatment without third party reimbursement is made by the patient in consultation with his or her physician. Thus, the person performing the utilization review is not diagnosing, operating on, prescribing for, administering to or treating any ailment, injury or deformity, but is merely deciding whether or not third-party payment is available.

LACY H. THORNBURG Attorney General

Mabel Y. Bullock Assistant Attorney General