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Managed Care Organizations and Liability

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1 - Liability of MCOs (managed care organizations) such as HMOs (health maintenance organizations) and PPOs (preferred provider organizations). Where does the liability lie for the managed care organization when the MCO personnel make decisions about insurance coverage for hospital stays? The analysis cannot be limited to analysis to length of stay, but other scenarios associated with MCO decision making such as approval or denial of medically necessary treatment (or limitations of treatment) list specific scenarios. Defend the stance thoroughly and include the potential liability implications.

2 - Discuss the options, if any, MCO or PPO plan members have when denied coverage for medically necessary care.

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This solution discusses Managed Care Organizations and liability.

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1 - MCOs are potentially liable for coverage decisions regarding hospital stays, as well as being liable for provider contracts wherein all willing provider statutes apply. The managed care industry is heavily regulated and must abide by individual state Departments of Insurance regulations as well as the federal Department of Labor under ERISA and DOL regulations. MCOs are potentially liable when healthcare provider's and their treatment provided is impacted by a flawed manage care process wherein issues regarding standard of care, physician ...

Solution provided by:
Raushaun Rigsby, MSc
Education
  • Associates of Arts , Lone Star Community College
  • Bachelor of Science , Sam Houston State University
  • Masters of Science, Kaplan University
  • Masters of Science , Kaplan University
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