Health benefit plans, health-care providers and their insurers face increasing lawsuits based on treatment decisions.SAN FRANCISCO--(BUSINESS WIRE)--Jan. 20, 1995--Health benefit plans, physicians and their insurance companies all face increased risk from legal suits based on decisions by HMOs and other third- party payors to deny treatment to patients, industry leaders were warned Friday at a meeting of the Physicians Insurers Association of America. "The utilization review u·til·i·za·tion review n. A process for monitoring the use, delivery, and cost-effectiveness of services, especially those provided by medical professionals. process -- the decision by a third-party payor to authorize To empower another with the legal right to perform an action. The Constitution authorizes Congress to regulate interstate commerce. authorize v. to officially empower someone to act. (See: authority) or withhold with·hold v. with·held , with·hold·ing, with·holds v.tr. 1. To keep in check; restrain. 2. To refrain from giving, granting, or permitting. See Synonyms at keep. 3. a medical procedure -- creates a significant new risk in health-care litigation An action brought in court to enforce a particular right. The act or process of bringing a lawsuit in and of itself; a judicial contest; any dispute. When a person begins a civil lawsuit, the person enters into a process called litigation. ," stated Los Angeles Los Angeles (lôs ăn`jələs, lŏs, ăn`jəlēz'), city (1990 pop. 3,485,398), seat of Los Angeles co., S Calif.; inc. 1850. attorney Curtis A. Cole, a partner of Thelen, Marrin, Johnson & Bridges and a leading health-care insurance litigator lit·i·gate v. lit·i·gat·ed, lit·i·gat·ing, lit·i·gates v.tr. To contest in legal proceedings. v.intr. To engage in legal proceedings. . "The Fox vs. Health Net jury verdict is the most dramatic illustration. Patients are accusing health-care providers, as well as the health benefit plans of making decisions based on financial motivations," Cole said. The Health Net situation may arise in other contexts, beside the question of experimental or investigational treatment, such as the bone marrow transplant bone marrow transplant: see bone marrow. procedure that was at issue in the Health Net case. For example, a suit could arise when a member of a private medical plan or HMO HMO health maintenance organization. HMO n. A corporation that is financed by insurance premiums and has member physicians and professional staff who provide curative and preventive medicine within certain financial, seeks treatment at a non-plan medical facility and is denied approval because the requested medical procedure does not specifically qualify under the plan or is deemed not to be medically indicated. "There is and there will continue to be an increasing number of claims against physicians that arise from utilization review and other managed-care decisions," Cole said. He also noted, "These claims will be not only for medical malpractice Improper, unskilled, or negligent treatment of a patient by a physician, dentist, nurse, pharmacist, or other health care professional. but also for other legal theories of recovery of damages. "This trend of suing many defendants -- in addition to the usual litigation between patients and physicians -- could become a significant problem if HMOs and other third-party payors are targeted," Cole emphasized. "One additional, surprising development is suits by health benefit plans against patients and health-care providers, using the very theories traditionally asserted by patients against health-care providers," added Cole. For example, a third-party payor may sue its own member to avoid paying his/her medical expenses -- as well as the insured's treating physicians -- arguing that the patient enrolled in the health benefits program, knowing he/she had a problem, but denying any such pre-existing condition. The plan might additionally sue the health-care providers for performing a procedure which created an additional medical problem, Cole noted. Then, in response, the patient might turn around and sue the insurer for breach of contract and sue the physicians for negligence. "Overall, despite the waning decision-making power of physicians in the HMO era, they still have the responsibility to be advocates for appropriate care -- even if authorization is denied," Cole stated. CONTACT: Lewis & Associates, Los Angeles Dick Lewis, 213/965-6041 |
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