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Shaw Chiropractic MANAGED CARE: THE PERSONAL INJURY DILEMMA A new client reports to your office with injuries which require medical care. They inform you that they plan to see their HMO doctor for treatment. Your first impression is that your client will receive the care they require and you will receive the medical specials necessary to document your clients physical damages. Also, because the medical bills are paid by a collateral source you believe that there will be more money in the settlement for you and your client. Unfortunately, there are several behind the seen dynamics which may adversely effect your clients case. The treating managed care doctor has concerns which from his perspective far outweigh the needs of a trial attorney. The HMO doctor believes he has only two responsibilities. He must provide his patient with the minimum care necessary to relieve and control the condition. He also is obligated to satisfy his HMO "employer" by containing costs. He has no incentive to document the physical damages should there be residuals or to offer his patient optimal care. In fact, he has a strong disincentive to provide these essential services. The end result is that the physician provides your client with the minimum care necessary with bills which are designed to satisfy the HMO utilization review supervisor. Your client does not receive optimal care nor does the case reflect the seriousness of your clients physical damages. From the HMO’s perspective, physicians which provide less care are better "managed care providers". They profile the doctors to determine if they are effective case managers. Doctors who treat beyond the utilization parameters established by the HMO are simply not invited to renew their contracts. Essentially they are fired. As a result, the pressure from the managed care organizations force the doctor to provide only that care which is necessary. This "necessary" care is usually far less than that which is optimal for recovery. How does all this effect the personal injury attorney and his clients case? First, the medical dollars permitted by most carriers for soft tissue rehabilitative care is so limited that there are practically no medical specials to mention. Usually only several hundred dollars including diagnostic procedures. Since the managed provider is contractually obligated to live within the parameters of the HMO he cannot bill in excess of the fee schedule. Neither can he bill for visits beyond those approved regardless of who offers to pay the bill. To pay a doctor more than the managed care approved amount can put both the attorney and doctor in jeopardy. The doctor is at risk because he is breaching his contractual agreement and therefore could be terminated from the panel of providers. The attorney risks being grieved by a client who is upset that he has disbursed funds which are rightfully the property of the client. Doctors have a choice to make. They must choose between doing what is best for the patient’s health (and case) or sell out to the HMO and provide the bare minimum of care. What it comes down to is that the managed care doctor cannot serve two masters. As council, you should advise your clients of this potential conflict of interest on the part of their HMO physician. They should be aware of how it may effect their case and health care. The ultimate choice is the patient’s but they need to be informed of their options Recent requests from attorneys have prompted
us to devote the next several newsletters
specifically to this topic. The next newsletters
will discuss how to handle claims adjustors
who argue for lower settlements due to
available collateral sources of payment.
We will also discuss specific limitations
of some of Connecticut’s popular
HMO’s. The insurance industry will
do anything possible to reduce the settlements
to your clients. We hope to provide you
with the necessary information so that
you can retort the often unreasonable
assertions of the adjustors. |
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