Question

you have learned about the liability of MCOs (managed care organizations) such as HMOs (health maintenance organizations) and PPOs (preferred provider organizations).where does the liability lie for the managed care organization when the MCO personnel make decisions about insurance coverage for hospital stays? Please do not limit your analysis to length of stay, but consider other scenarios associated with MCO decision making such as approval or denial of medically necessary treatment (or limitations of treatment) as well, and share your scenarios with the class. Defend your response thoroughly and include the potential liability implications. Lastly, discuss the options, if any, MCO or PPO plan members have when denied coverage for medically necessary care.

Answer 1

Managed care organizations - they are organization whose main aim is to provide patients with appropriate and cost effective medical treatment. HMO's ( health maintenance organizations) and PPO's ( preferred provider organizations) are the different types of such providers of CMO's.

• So they achieve this reduced cost by including the doctors who are in the contract and not all doctors are included only those who provide cheap services.
• MCO restrict the treatment given for the patient and also restrict them from consulting it to a specialist.
• Selected care provider negligance
• Fee for service and consultation to a specialist later also brings only extra cost for the patients.
• Unable to credential a provider who is under malpractice
• Record keeping and exposure of exposure of confidential data.
• Medical care substituted with substandard care for the sake of financial incentives.
• Supervision of the care given for the patients
• No action taken against any incorrect actions by the physician in the care provided.
• Neglect selection of a provider.

Thus information regarding all these should be considered while selecting a company for managing care.

They can deny any coverage by the following reasons

• That thec recipient is not in claim with the CMO
• Too early or delayed claiming
• Claim being the duplicate of a already paid claim.
• Deadline date over
• Error in preparation of the claim paper