Whodunit? Causal responsibility of utilization review for physicians' decisions, patients' outcomes

In the “olden days,” only a few years ago, physicians were free to order virtually any service they believed their patients needed, confident that virtually everything would be paid for. Reimbursernent was retrospective, fee-for-service and generous, essentially a cost-plus system in which insurers only rarely challenged medical decisions. That system is now gone. Uncontrolled escalations in the cost of health care have prompted those who pay its costs—primarily governments, businesses, and insurers—to initiate a broad array of cost controls in hopes of at least restraining the rise of their expenditures, even if not actually reducing them. Among the most prominent cost-containment mechanisms is utilization review (UR).

Insurers have always engaged in retrospective review, denying payment for services that are not medically necessary, or not covered by the patient's policy, or not documented in the patient's records. Recently, however, payers have added prospective review, in which physician and patient must secure advance payer approval for certain interventions if they wish to ensure reimbursement.

Trends in utilization management: legal implications for health records administration

Utilization management will continue, under whatever label or within whatever framework, to demand the attention of records administrators. Since all quality and utilization review is ultimately based on the data in the medical record, the role of health record administrators is central to this activity. As programs and requirements continue to evolve, successful health care providers will draw on educated records professionals to assist in successful management strategies.

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); mental health services--Department of Defense. Final rule

This final rule establishes a mandatory preadmission authorization program for mental health services under CHAMPUS. Such a program is needed to promote quality assurance and contain rapidly increasingly costs in inpatient psychiatric care under CHAMPUS. By maintaining most of the procedures of the current voluntary preadmission authorization program, the final rule minimizes inconveniences for providers.

Employers balk at provider-backed efforts to limit reach of utilization-review firms

Businesses are beginning to take more of an interest in the way some states are regulating utilization review firms. Employers complain that provider-backed laws are restricting the use of utilization review, a key tool in containing healthcare costs.

Federal court assumes ERISA claims jurisdiction

In a recent appellate court decision, a practitioner was granted the right to challenge a claims denial under provisions of the Employee Retirement Income Security Act of 1974. This article reviews the reasoning of the court in allowing the practitioner standing in the court under ERISA and reviews the language of the insurance contract that led the court to affirm denial of payment to the practitioner. "Health Law" is a regular feature of Physician Executive contributed by Epstein Becker & Green. Mark E. Lutes of the law firm's Washington, D.C, offices serves as editor for the column.

Coverage, technology assessment, and the courts

Coverage decisions by third-party payers are relying more and more heavily on the conclusions of technology assessment programs about the safety and effectiveness of technologies applied in specific clinical situations. Assessment programs vary markedly in the sophistication and rigor of their methodology. Payers differ as to how such assessment information is integrated into their decision-making processes. Finally, coverage decisions about a specific technology can vary widely across the country.

California's Wickline decision revisited

In a recent California appellate decision, Wilson v. Blue Cross of Southern California, 222 Cal. App 3d 660, 271 Cal Rptr 876 (2d Dist., 1990), the court cut back on its earlier decision in Wickline v. State of California, 192 Cal. App. 3d 1630, 239 Cal Rptr 810 (2d Dist. 1986), which had provided substantial protection for third-party payers against liability for utilization review decisions. The Wilson decision not only limits Wickline to its particular facts, but also criticizes some of its rationale.

Liability for medical record disclosure is real but rare

The most recent public concern for patient confidentiality has centered on the medical records of AIDS patients. However, a new confidentiality concern is the liability of the self-insured hospital that reviews medical claims internally. Also, the sometimes conflicting demands of protecting patient confidentiality and being reimbursed in a timely fashion are setting off sparks between the medical records department and the business office.

The liability of payors and providers in health care treatment decisions

Who is legally liable for health care treatment decisions--payors or providers? Nurses need to understand the implications of recent court decisions that deal with this question.

New developments in managed care litigation

This article discusses recent litigation attempting to impose liability for managed care decisions on alternative delivery systems and recent state legislation allocating such liability among the participants in managed care programs.

An advance in Medicare advocacy: protecting patients from arbitrary coverage denials

The increase in arbitrary Medicare coverage denials has resulted in the degradation of American medical care. In this article, the authors discuss the positive impact of one Connecticut case, Fox v. Bowen, on the effort to end improper coverage denials.

The erosion of physician-patient privilege and patient confidentiality

With the proliferation of third party payers for health care who exercise utilization management, there has been an erosion of the physician-patient privilege and patient confidentiality. The kinds of medical information obtained by third party payers under the guise of claims administration violate the spirit if not the actual laws pertaining to physician-patient communication. It presents three episodes involving the first author in which that communication was violated by third parties administering health care benefits. Recommendations are made to protect that confidentiality in this era of increasing cost management.

Medicare program, data, standards and methodology used to establish budgets for fiscal intermediaries and carriers--HCFA. Final notice with comment period

This notice describes the data, standards, and methodology that we will use to establish fiscal intermediary and carrier budgets for fiscal year (FY) 1990. Intermediaries and carriers assist in the administration of the Medicare program by performing numerous functions related to paying for medical services and equipment. This notice implements section 4035(a) of the Omnibus Budget Reconciliation Act of 1987 (Pub. L. 100-203). Section 4035(a) requires us to publish for public comment in the Federal Register data, standards, and methodology we will use to establish budgets for Medicare intermediaries and carriers.

Patient care decisions and employer liability

The foregoing discussion has raised numerous issues respecting potential liability for home health care providers resulting from utilization management entity activities and related provider, employee, and subcontractor decisions made in the patient care process. Knowledge of these issues without corrective action by providers is fraught with risk. The development and maintenance of written policies and procedures along the lines suggested will not only minimize employer and employee liability arising from these activities, but will also facilitate effective patient advocacy.

"Medically unnecessary" letters create frustrating puzzles

Medicare's "medically unnecessary" letters are frustrating puzzles to the many Texas physicians who receive them. While the letters question the medical necessity of care, they provide physicians with no basis for understanding and responding to that allegation. Medicare uses computerized screens to review claims, and it is those screens that are primarily responsible for the generation of "medically unnecessary" letters. The accompanying list of Medicare review screens provides a general clarification of what Medicare is looking for in the review process. The word "general" is an important qualification: there is no guarantee that a physician will be able to identify from the list the particular screen that has caused Medicare to request more information about a particular claim. But the list will help the practitioner in understanding what Medicare sees as the boundaries of customary medical practice and, in some instances, will help the physician respond to Medicare's request for additional information. With that broad introduction Texas Medicine presents the following guide to Medicare's claims screening criteria. It was prepared by the Texas Medical Association's Division of Medical Economics based on materials published by Medicare.

Legal problems of health care cost containment

Employers faced with rising health care costs are exploring various means to control them. One way is prospective utilization review, although this may pose significant legal risks. Another is the capitation form of payment in which an employer contracts with a health care provider either directly or through an employer-sponsored HMO. The authors discuss these alternatives and the implications for employers.

Potential liability in utilization review

Increasingly, utilization review activities arising out of the cost containment concerns of third-party payers and the business community are becoming a factor in the health care delivery process. The author focuses on the potential liability of the physician and the utilization review organization when a patient suffers injury following a disagreement about treatment and urges the physician to deliver necessary services according to his or her medical judgments, not the judgement of the utilization review organization.