The devil is in the details: Managed care and the unforeseen costs of utilization review as a cost containment mechanism.

Abstract

This article addresses issues of liability when a single-payor in a national health care system makes a decision based on a utilization review program that injures the patient as a result. In Part I, the history of Managed Care Organizations (MCOs) is discussed to establish an understanding of the current health care landscape. Part II explains MCOs' use of utilization review to contain costs and analyzes the manner in which courts have addressed the issue of MCO liability for patient injuries sustained from denial ofcoverage. Finally, Part III concludes that current case law may limit a patient's access to a remedy for injuries sustained from a utilization review decision in a single-payor national health care system.

• Authors: Benjamin Saunier
• Journal: Issues in law & medicine (Issues Law Med) Vol. 27 Issue 1 Pg. 21-48 ( 2011) ISSN: 8756-8160 [Print] United States
• PMID: 21919314 (Publication Type: Journal Article)

Topics

• Cost Control
• Humans
• Liability, Legal
• Managed Care Programs (economics, legislation & jurisprudence)
• United States
• Utilization Review