450+ experts on 30 subjects ready to help you just now
Starting from 3 hours delivery
Pssst… we can write an original essay just for you.
Any subject. Any type of essay. We’ll even meet a 3-hour deadline.Get your price
121 writers online
Health Maintenance Organizations work closely with patients to connect them to providers who can provide the care they need. In return the HMO receives a set payment with is arranged with the insurance company. Providers must apply to be in the network. For a provider to become an in-network provider they must have specific credentials to prove the quality of care will be met. This assures providers meet the care requirements and are less likely to have malpractice issues, however should they run into issues they must have malpractice insurance to cover them. HMO’s vet potential providers before approving them to be in-network due to the liabilities that can fall on the HMO for approving that provider. (DiCicco, 1998)HMO’s help reduce unnecessary emergency and specialists visits by requiring a referral from their primary care physician. This cuts costs and delegates patients to the proper providers; however, it can be difficult for patients who require care in a quicker manner than they are able to obtain due to the referral process. Assigning, receiving, and processing referrals can be a time-consuming process for larger practices which can cause strain on staff members as well as patients whom are waiting for the referrals to seek further treatment. (Steele, 2013).
An example of this process causing medical crisis’ for patients and malpractice suits against provider is the 1988, Boyd v. Albert Einstein Medical Center case. A patient needed a biopsy done and upon receiving the testing she was injured further which continued to get worse. Being that she had an HMO she returned to the primary provider she originally received a referral from, but it was not enough. This patient needed emergency care which the provider did not refer her to. Instead she received testing which would take days to receive results on. Had she been transferred to the emergency room, she could have had her test results sooner and possibly a different health outcome. The patient lost her life due to the negligence of the provider performing the tests knowing results would not be timely. (Hall, & Orentlicher, 2013, p. 129). HMO’s must watch their referral and refusal actions carefully, to not risk an HMO negligence case. Reasons these cases can be brought up are:
There is the possibility of lawsuits against the HMO in these situations can be malpractice by doctor, wrongful death due to the denial to specific needed services and resulting in the loss of a patient’s life, as well as bad faith suits for denying claims which should have been paid without issue. An insurance company cannot deny routine covered services without reason. Legitimate reason must be given for every denied claim. Services considered non-medically necessary may not be covered or may require authorization. An example is acupuncture with is considered alternative medicine and not proven necessary. Plastic surgery is not covered unless deemed medically necessary and authorized by the HMO. (Sterodimas, Radwanski, & Pitanguy, 2011).
We provide you with original essay samples, perfect formatting and styling
To export a reference to this article please select a referencing style below:
Sorry, copying is not allowed on our website. If you’d like this or any other sample, we’ll happily email it to you.
Attention! This essay is not unique. You can get a 100% Plagiarism-FREE one in 30 sec
Sorry, we could not paraphrase this essay. Our professional writers can rewrite it and get you a unique paper.
Please check your inbox.
Want us to write one just for you? We can custom edit this essay into an original, 100% plagiarism free essay.Order now
Are you interested in getting a customized paper?Check it out!