Managed Care

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Managed Care

By Cliff Rapp, LHRM, Vice President of Risk Management, FPIC

Within the last 20 years the presence of managed care in the healthcare industry has dramatically increased. In addition to the influence that managed care has had on healthcare delivery is the potential for increased liability exposure beyond that inherent to the physician-patient relationship. Therefore, it is important that physicians who participate in managed care implement effective risk management techniques designed to reduce the frequency and severity of claims arising from evolving managed care issues.

Understanding Managed Care

Managed care may be defined as a set of techniques used by, or on behalf of, purchasers of healthcare benefits to manage costs by influencing patient care decision-making prior to the provision of services.

Traditionally, the strength of a physician-patient relationship was measured in terms of loyalty. Establishing a solid physician-patient relationship has long been acknowledged as a significant factor in the avoidance of malpractice claims. Since the advent of managed care, loyalty is often tied to the contractual relationship of the managed care plan. However, participating in managed care does not have to negatively impact a physician's liability exposure.

In light of the way patients must access their medical care and treatment, it is essential to remain the patient's advocate. In this context, reducing exposure to malpractice claims attributed to the managed care process requires that a physician adhere to the utilization review process set forth by the patient's managed care plan.

Establishing realistic patient expectations is another major factor determining claim exposure. Educate the patient about the managed care process, including the confines set forth by their insurance coverage. Advise patients of any financial restrictions or limitations set forth. Inform patients about the managed care process, such as the authorization entailing recommended care and treatment.

Risk Management Guidelines

Reduce your exposure to liability attributed to managed care issues and potential system failures by implementing the following risk management guidelines:

Provide patients with an informational brochure about you and your practice. Design the brochure with sufficient space to allow your office staff to insert the name of the patient's managed care plan, the patient's membership number, and the plan's telephone and fax numbers.
Protect patient confidentiality. Obtain the patient's authorization to release records to the managed care provider.
Refer to the plan's provider contract or agreement before terminating the physician-patient relationship or withdrawing from participation in the plan.
Determine what the plan's protocols require and adhere to them.
Document your care and treatment fully, including requests for referrals or extension of care.
Copy the patient with correspondence evidencing your advocacy on their behalf.
Inform patients about the nuances of the managed care process and the requirements, limitations, or protocols set forth by their plan.
Fully inform the patient. Explain the potential consequences of foregoing recommended care or treatment not covered by the plan. Send the patient written confirmation of your recommendation, their acknowledgement of the potential ramifications, and their refusal to accept financial responsibility independent of the plan.
Seek guidance from your personal attorney or liability carrier whenever you encounter managed care protocols that are unclear, compromise your care and treatment, or could increase your liability exposure.