HMOS' RESPONSIBILITY TO PATIENTS

HMO physicians occupy dual roles. They act as insurance plan administrators in making decisions regarding the coverage and services available to patients and they act as health-care providers when making decisions regarding a patient's treatment. Both Pennsylvania and federal courts have identified three types of decisions that HMO physicians make. "Pure eligibility decisions" focus on the policy's coverage of particular conditions or medical procedures. "Treatment decisions," by contrast, are choices about how to best diagnose and treat a patient. "Mixed eligibility and treatment decisions" are decisions in which both coverage questions and medical judgment are involved. Such decisions include the doctor's choice of diagnostic tests, the doctor's decision to use outside consultants, specialists, or facilities, the doctor's determination of whether a situation is an emergency, and the doctor's decisions regarding standards of care.

Recently, the Pennsylvania Supreme Court decided that individual patients have the right to sue HMOs and HMO physicians for medical malpractice in the making of mixed eligibility and treatment decisions. In the case at issue, a patient suffering from paralysis and numbness in his extremities was initially treated at a small community hospital and was diagnosed as suffering from a neurological emergency arising from a spinal infection. When the emergency room doctor sought approval from the patient's HMO to move him to a particular regional hospital that was ready to accept him for immediate emergency neurological surgery, the HMO refused the transfer because the regional hospital was not a member of the HMO. Over the next three hours, the emergency room doctor tried to arrange for prompt treatment at the other regional hospitals the HMO was willing to approve. The patient finally was moved to an approved regional hospital approximately four hours after his admission to the community hospital emergency room. Following his surgery and hospitalization, the patient's recovery was not successful; suffering from permanent quadriplegia, he sued the HMO and its decisionmaking physicians, claiming that the four-hour delay prevented his receiving successful surgery.

The Pennsylvania Supreme Court found that HMOs and their physicians are subject to suit in Pennsylvania courts and are not protected by federal laws limiting the kinds of suits that can be brought against employment benefit providers. Concluding that a decision on whether to move an emergency patient to a nonmember hospital that can accept the patient immediately is a mixed decision and not a coverage decision, the court upheld the patient's right to take his case against the HMO and its doctor to trial.

At trial, the patient will have to prove that his permanent disability is the direct result of the delay in his treatment. Patients who are not treated or not treated in a timely manner need also prove that they requested better or earlier health-care services. If you are dissatisfied with a decision by an HMO administrator or physician, be sure to keep clear records of the timing of your requests and the reasons given for the refusal of services.

The information you obtain at this site is not, nor is it intended to be, legal advice. You should consult an attorney for individual advice regarding your own situation.

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