Biomaterial Database

Managed care liability update. 1997

J Fiesta

As the volume of litigation involving managed care grows, the liability issues become clearer. For example, recent decisions demonstrate that failure to provide access to qualified physicians, failure to process claims appropriately, denial of claims and undue delay of treatment can and do lead to liability. Moreover, the federal Employment Retirement Income Security Act of 1974 (ERISA) won't protect the managed care providers, and physicians may sue the managed care organization if its policies or agents open them to liability.

UI	MeSH Term	Description	Entries
D007345	Insurance Claim Review	Review of claims by insurance companies to determine liability and amount of payment for various services. The review may also include determination of eligibility of the claimant or beneficiary or of the provider of the benefit; determination that the benefit is covered or not payable under another policy; or determination that the service was necessary and of reasonable cost and quality.	Claims Review,Insurance Audit,Insurance Claims Processing,Analysis, Claims,Claim Review, Insurance,Claims Analysis,Insurance Claims Analysis,Review, Claims,Review, Insurance Claim,Analyses, Claims,Analyses, Insurance Claims,Analysis, Insurance Claims,Audit, Insurance,Audits, Insurance,Claim Reviews, Insurance,Claims Analyses,Claims Analyses, Insurance,Claims Analysis, Insurance,Claims Processing, Insurance,Claims Reviews,Insurance Audits,Insurance Claim Reviews,Insurance Claims Analyses,Processing, Insurance Claims,Reviews, Claims,Reviews, Insurance Claim
D008318	Malpractice	Failure of a professional person, a physician or lawyer, to render proper services through reprehensible ignorance or negligence or through criminal intent, especially when injury or loss follows. (Random House Unabridged Dictionary, 2d ed)	Professional Negligence,Negligence,Negligence, Professional,Professional Negligences
D008329	Managed Care Programs	Health insurance plans intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases. The programs may be provided in a variety of settings, such as HEALTH MAINTENANCE ORGANIZATIONS and PREFERRED PROVIDER ORGANIZATIONS.	Case Management, Insurance,Insurance Case Management,Managed Health Care Insurance Plans,Managed Care,Care, Managed,Managed Care Program,Management, Insurance Case,Program, Managed Care,Programs, Managed Care
D006801	Humans	Members of the species Homo sapiens.	Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D014481	United States	A country in NORTH AMERICA between CANADA and MEXICO.
D016365	Liability, Legal	Accountability and responsibility to another, enforceable by civil or criminal sanctions.	Institutional Liability,Personal Liability,Professional Liability,Legal Liability,Medical Liability,Torts,Institutional Liabilities,Legal Liabilities,Liabilities, Institutional,Liabilities, Legal,Liabilities, Medical,Liabilities, Personal,Liabilities, Professional,Liability, Institutional,Liability, Medical,Liability, Personal,Liability, Professional,Medical Liabilities,Personal Liabilities,Professional Liabilities,Tort