Health Maintenance Organizations and Malpractice

Introduction

Health Maintenance Organizations (HMOs) work closely with patients to connect them to providers who can deliver the care they need. In return, the HMO receives a set payment arranged with the insurance company. Providers must apply to be in the network. To become an in-network provider, they must have specific credentials to prove that the quality of care will be met. This ensures that providers meet care requirements and are less likely to have malpractice issues. However, should they encounter problems, they must have malpractice insurance to cover them. HMOs 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). HMOs help reduce unnecessary emergency and specialist visits by requiring a referral from the primary care physician. This cuts costs and delegates patients to the proper providers; however, it can be difficult for patients who require care more quickly 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 who are waiting for the referrals to seek further treatment (Steele, 2013).

Health Maintenance Organizations and Malpractice

An example of this process causing medical crises for patients and malpractice suits against providers 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. As she had an HMO, she returned to the primary provider from whom she originally received a referral, but it was not enough. This patient needed emergency care, which the provider did not refer her to. Instead, she received testing that would take days to yield results. 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). HMOs must carefully monitor their referral and refusal actions to avoid risking an HMO negligence case.

Reasons for Malpractice Cases

Reasons these cases can be brought up include:

• Denying necessary diagnostics in life-threatening cases
• Refusing referral requests that are necessary (including to providers outside of the network, when necessary)
• Refusing to transfer a patient to another facility when needed (if the current facility cannot provide required diagnostics or treatments)
• Refusal to seek second opinions from outside providers when an in-network provider is not sufficient

There is the possibility of lawsuits against the HMO in these situations, which can include malpractice by a doctor, wrongful death due to the denial of specific needed services resulting in the loss of a patient’s life, as well as bad faith suits for denying claims that should have been paid without issue. An insurance company cannot deny routine covered services without reason. Legitimate reasons must be given for every denied claim. Services considered non-medically necessary may not be covered or may require authorization. An example is acupuncture, which 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). It is crucial for HMOs to establish clear guidelines and communication channels to ensure that necessary services are provided promptly and efficiently.

Conclusion

In conclusion, while HMOs play a significant role in managing healthcare costs and improving service delivery, they must exercise caution in their referral processes to avoid potential legal and ethical pitfalls. The balance between cost-saving measures and ensuring timely, necessary care is delicate and requires constant vigilance and adaptation to changing healthcare needs.

References

DiCicco, G. (1998). Health Maintenance Organizations and Network Providers. Journal of Health Management, 12(3), 45-56.

Hall, M. A., & Orentlicher, D. (2013). Health Care Law and Ethics. Aspen Publishers.

Steele, J. (2013). Challenges in Health Care Referrals. Medical Practice Management Journal, 27(4), 78-82.

Sterodimas, A., Radwanski, H. N., & Pitanguy, I. (2011). Understanding Health Insurance Coverage and Limitations. Aesthetic Surgery Journal, 31(8), 1026-1035.