Direct Legal Responsibility, Essay Example

Direct legal responsibility applies when the MCO is the key offender. Explicit accountability holds MCOs to secondary liability as a result errors that a primary treating physician may have made. A great deal of guidelines is not clear and makes it difficult to determine exactly what direct constitutes liability. Several guidelines are so ambiguous that they actually create a vicarious liability. For example, many of the guidelines use language in such a way that there are many loop holes that can be used to deny services. Consequently, interpretation of the guidelines needs to refined and made clearer through court mandation.  There are many preconditions about bring suit upon a managed care facility. Some states have limitations on the degree to which the patient was injured (California, Georgia, New Jersey, and Washington).  Other states require external review before the patient can sue for damages (Arizona, California, Georgia, New Jersey, and Texas). Each HMO plan limits the members’ rights to appeal decisions for denial of services. However, many HMO plans offer a point-of-service option. When patients choose this option, they are allowed to see doctors or providers that are not in the HMO network. They can also see specialist without being referred.  On the other hand, PPOs operate the same as the point-of –service option offered by HMO. When members of PPO receive services from within their network, the services are cheaper. If they choose to go outside the network, they are willing to pay more. PPO does not require patients to be referred by a primary physician. Managed care facilities function a gatekeeper for the clients. They must be advocates for the best interest of their clients. Consequently, it is the facilities responsibility to ensure that they refer clients to specialist when it is necessary. Many facilities have faced liability charges for not referring clients and causing their HMO to deny them needed services.