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Related Experiment Videos

Managed care liability and the capitated provider.

M E Reagan

    Health Care Law Newsletter
    |September 5, 1995
    PubMed
    Summary
    This summary is machine-generated.

    The Employee Retirement Income Security Act (ERISA) may preempt provider utilization review claims. Providers in capitated arrangements should monitor this developing legal issue and secure appropriate insurance coverage.

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    Area of Science:

    • Healthcare Law
    • Health Insurance Policy
    • Risk Management in Healthcare

    Background:

    • Capitated arrangements shift financial risk to providers.
    • Utilization review decisions by providers are increasingly common.
    • The legal landscape regarding ERISA preemption in healthcare is evolving.

    Purpose of the Study:

    • To analyze the potential impact of ERISA preemption on provider utilization review decisions.
    • To identify risks faced by providers under capitated arrangements.
    • To provide guidance on managing legal exposure related to utilization review.

    Main Methods:

    • Legal analysis of ERISA preemption principles.
    • Review of existing case law and potential future litigation trends.

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  • Examination of contractual implications for providers and health plans.

    • Main Results:

    • No current case law exists on ERISA preemption of provider utilization review claims.
    • Lack of preemption could expose providers to significant liability, shielding health plans.
    • Insurance for punitive damages related to these claims is unlikely to be available.

    Conclusions:

    • Providers in capitated arrangements must proactively address the potential for ERISA preemption.
    • Securing adequate liability insurance and negotiating favorable contract terms are crucial risk mitigation strategies.
    • Providers should ensure contracts clarify that utilization review is performed on behalf of the health plan, covered by their insurance.