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Minimizing Physicians' Managed Care Liability |
Physicians face expanded liability under managed care because federal law does not hold managed care organizations (MCOs) accountable for malpractice. Therefore, the onus of patient care falls on physicians. Yet as the patient’s advocate, physicians’ medical decisions may contradict the demands of the MCO. When that happens, ISMIE recommends that physicians appeal any decision opposing what they consider the best medical treatment for their patient.
Case law supports ISMIE’s standpoint. In Wickline vs. California, a California Appeals Court said the treating physician was responsible for determining length of hospital stays. The physician sought eight days, but the plan approved only four. The patient developed gangrene after being sent home too early and had to have a leg amputated. The court ruled that the physician should have appealed the reduced stay.
Changes ahead? Physicians may get relief. The U.S. House and U.S. Senate must reconcile dueling patient rights bills, one of which gives patients the right to sue their MCOs. Meanwhile, the Illinois Supreme Court’s recent Petrovich vs. Share ruling holds MCOs accountable for decisions that harm patient care. In addition, the current U.S. Supreme Court docket includes another Illinois case involving MCO liability, Pegram vs. Herdrich.
ADDITIONAL MANAGED CARE LIABILITY HAZARDS.
ISMIE’s advice on other managed care risks physicians confront includes the following:
! BE A PATIENT CARE COORDINATOR. A physician is responsible for overseeing a patient’s care, including referrals to specialists. In one case, a doctor who had been newly named as the plaintiff’s primary care physician referred the patient to the hospital. However, the doctor never saw the patient prior to making the treatment decision, and later failed to follow up on an ID consult. A delay in medical treatment led to the patient’s death.
! PREVENT COMMUNICATION COLLAPSES. It’s the doctor’s job to communicate with the MCO regarding authorizations for care and provide the explanation for why certain procedures or tests are needed. Physicians should not take no for an answer, but advocate for their patients and appeal MCOs’ denials.
! AVOID DOCUMENTATION OMISSIONS. In another case, the primary care physician received authorization for the patient to be referred to a specialist for tests. The patient did not follow up on the tests, but the physician avoided liability for the patient’s subsequent illness because he had documented the referral.
Take Action. Despite the increased liability risks associated with MCOs, physicians can protect themselves. Adopting the steps listed above ensures that physicians have a record of the quality care they provide to their patients should questions arise later. For more information, contact ISMIE’s Risk Management Department at 800-782-4767.