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Related Experiment Videos

Managed care under fire.

W A Sarraille1, M F Tatelbaum

  • 1Arent Fox Klinter Plotkin & Kahn, PLLC, 1050 Connecticut Avenue NW, Washington, DC 20036, USA. sarrailw@arentfox.com

Pain Physician
|August 15, 2006
PubMed
Summary
This summary is machine-generated.

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Litigation against managed care organizations shows mixed results. While physicians and plan members face challenges, state enforcement agencies achieve success, particularly with prompt payment regulations.

Area of Science:

  • Healthcare Law
  • Health Policy
  • Managed Care Litigation

Background:

  • Managed care litigation and legislation have seen increased activity.
  • Common legal actions involve payment disputes, network issues, breach of duty, and fraud.

Purpose of the Study:

  • To analyze the outcomes of recent litigation and legislative actions involving the managed care industry.
  • To identify trends and varying degrees of success among different parties involved in these disputes.

Main Methods:

  • Review of litigation and legislative outcomes concerning managed care organizations.
  • Categorization of common legal claims and their resolution.
  • Analysis of success rates for physicians, plan members, and regulatory agencies.

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Main Results:

  • Physicians generally struggle in financial lawsuits against managed care organizations unless state regulators intervene.
  • Plan members experience some success, especially when care denial leads to injury.
  • State enforcement agencies are the most successful litigants, particularly in enforcing prompt payment regulations.
  • Managed care organizations effectively use ERISA preemption to defend against suits from plan members.

Conclusions:

  • Despite varied success, a widespread perception exists that the managed care industry prioritizes profits over patient health.
  • Legal and regulatory actions highlight ongoing tensions between managed care entities, providers, and consumers.