Managed Care Organizations and Liability
1 – 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? The analysis cannot be limited to analysis to length of stay, but other scenarios associated with MCO decision making such as approval or denial of medically necessary treatment (or limitations of treatment) list specific scenarios. Defend the stance thoroughly and include the potential liability implications.
2 – Discuss the options, if any, MCO or PPO plan members have when denied coverage for medically necessary care.