Avoiding HMO liability for utilization review.

Abstract

In this article, the author describes the potential liability of Health Maintenance Organizations for utilization review programs. Utilization review is used to determine whether certain medical treatment is necessary according to the standards of the HMO, and the HMO may decline to pay for treatments it deems unnecessary. If a doctor abstains from treatment because of this decision and the patient is harmed, the HMO may become the target of litigation. The author analyzes several recent cases and offers practical ideas for preventing and defending suits brought against HMO's for utilization review decisions.