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Avoiding HMO liability for utilization review.

M A Dowell

    Specialty Law Digest. Health Care Law
    |April 8, 1993
    PubMed
    Summary
    This summary is machine-generated.

    Health Maintenance Organizations (HMOs) face potential liability for utilization review decisions. This analysis examines cases where denied treatments led to patient harm, impacting HMOs legally.

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    Area of Science:

    • Healthcare Law
    • Medical Liability
    • Health Policy

    Background:

    • Health Maintenance Organizations (HMOs) utilize utilization review to assess medical necessity.
    • HMOs may deny payment for treatments deemed unnecessary based on their standards.
    • Patient harm resulting from treatment abstention due to HMO decisions can lead to litigation.

    Purpose of the Study:

    • To analyze the potential liability of HMOs concerning utilization review programs.
    • To examine recent case law related to HMO utilization review decisions.
    • To provide practical strategies for preventing and defending against lawsuits targeting HMOs for utilization review outcomes.

    Main Methods:

    • Review of legal precedents and case studies involving HMO utilization review.

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  • Analysis of legal arguments and potential defenses in litigation against HMOs.
  • Identification of risk management strategies for healthcare organizations.

    • Main Results:

    • HMOs can be held liable when utilization review decisions result in patient harm.
    • Recent cases highlight the legal risks associated with denying necessary medical treatments.
    • Proactive measures and robust defense strategies are crucial for HMOs.

    Conclusions:

    • HMOs must carefully manage utilization review processes to mitigate legal risks.
    • Defending against litigation requires a thorough understanding of case law and liability standards.
    • Implementing preventative strategies can significantly reduce the likelihood of successful lawsuits.