Magazine article Medical Economics

When a Plan's Policies Put You at Legal Risk

Magazine article Medical Economics

When a Plan's Policies Put You at Legal Risk

Article excerpt

You want your patient to remain in the hospital, but his managed-care plan refuses to pay for additional days. Who's liable when, after the early discharge, he takes a turn for the worse? In some circumstances, say legal experts, it's you.

With most plans, of course, physicians have little or no say about coverage and utilization policies. Yet, "in recent cases, the courts have said it's the physician's responsibility to try to overturn any insurance restriction that will harm his patient," explains Chicago health-law attorney Jerry P. Clousson.

Carefully worded contracts, along with ERISA--the federal law that protects employer-sponsored health plans--have generally shielded managed-care plans from liability in cases in which cost-containment policies hurt patients. It also shields their agents, such as utilization review companies.* But, Clousson says, when a physician adheres to those same insurer policies, he does so at substantial risk.

So, what do you do when your medical opinion runs counter to that of a UR firm, or when you believe your patient needs a treatment that the health plan doesn't want to cover? Start with a formal appeal to the medical director, advises Charlotte, N.C., health-law attorney Keith M. Korenchuk. Even if you don't prevail, the appeal may help protect you from liability.

Guidelines for appealing utilization and coverage decisions, therefore, need to be carefully spelled out in the negotiation of any managed-care contract. …

Search by... Author
Show... All Results Primary Sources Peer-reviewed

Oops!

An unknown error has occurred. Please click the button below to reload the page. If the problem persists, please try again in a little while.