Managed Care: Grievances, Appeals, and Potential Litigation


Summary

This practice note discusses grievances, appeals, and potential litigation that can arise in the context of managed care. All three can result from the complete or partial denial of a subscriber's referral for a second opinion, the performance of a medical service, or a referral for a medical procedure. The difference between the conduct of a medical procedure and a referral for one recognizes that some forms of managed care plans and entities themselves render medical care, while some serve primarily in the role as entities for cost containment and utilization review. Managed care plans exist for private health insurance and for what might be called public health insurance, such as Medicare and Medicaid. In all cases, the underlying purpose is essentially the same: cost containment.