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5 Cards in this Set
- Front
- Back
Laws (and Court Statutes) governing MCO’s
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standards of quality
grievance procedures On Federally Qualified HMO’s: peer review req’d UM and QM reporting req’d |
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Punishments for an MCO that acts illegally
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regulatory oversight
Punitive and Civil damages in the $100 millions forced to cease doing business suspension of license revocation of federal qualification |
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Illegal Actions by MCO’s (as per Court decisions and lawsuits)
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Improper Denial of Care (later found to be medically necessary)
Bad faith actions (too-slow authorization) Negligence in program design compensation (providers deny care; referrals too limited) selection or supervision of providers “vicarious liability” even independent providers’ mistakes cost the MCO legal damages. |
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Difficulties in Determining whether an MCO is liable for damages
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ERISA preempts State laws
ERISA limits damages Tough question: Does ERISA preempt punitive damages for negligence? ERISA plan sponsor must disclose any conflict of interest |
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Recommendations to an MCO on How To Avoid Legal Damages
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Monitor court decisions
Comply with ERISA clearly exclude coverage of transplants, etc. promotional brochures match the contract. clearly identify responsibility for independent providers’ actions. thoroughly review before denying authorization (e.g. life-or-death situation?) offer other treatment options assess current technology (still “experimental”?) Establish medical policies (follow ASoP) Establish appeal/grievance processes for Providers and Members. Give provider bonuses based on: Quality, Compliance, and E-Commerce. Not just low utilization Credentialing. UR QM Use Peer Review terminate poor providers (else $$$ legal damages) Purchase malpractice insurance Hire legal counsel. Done. |