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Health maintenance organizations, or HMOs, are one of the most popular forms of health insurance. Many workers receive HMO plans through their employers. HMOs place certain restrictions on doctors who accept patients with these plans, and give primary care physicians a particularly important role in the patient’s health.
What is an HMO?
HMOs are health plans that provide health services to members located in certain geographic regions in exchange for regular, fixed payments. HMOs became popular in the 1970’s when politicians backed the Health Maintenance Organization Act of 1973 as a step towards nationalized health care.
HMOs are run using either a staff, group, or network model. The staff model is the most common form; under it the HMO owns the healthcare facility where physicians are employed by the HMO practice. The group model involves a group of physicians contracting with the HMO allowing them to treat both patients with HMOs as well as patients with other insurances. The network model involves HMO contracts with multiple groups of physicians that members of the HMO can visit for prepaid health care services.
HMOs exercise more control over physicians than other healthcare plans because they require all members of the plans to maintain a primary care physician as the gatekeeper to the patient’s health. Members of HMO plans cannot see specialists without first visiting a primary care physician.
As prepaid plans, HMOs remove certain barriers to healthcare. Doctors face fewer concerns when they know that HMO patients can afford necessary healthcare because of the full coverage.
Medical Malpractice and HMOs
HMOs are notoriously difficult to sue for medical malpractice. Most states have ruled that HMOs are covered by the Employment Retirement Income Security Act (ERISA) of 1974 meaning HMOs are covered under federal law, not state, and cannot be sued by the state. Some states made rules that allowed for suing HMOs, but the Supreme Court ruled against the states and confirmed that federal law has presidence over state law. All insurance plans provided by employers are covered under ERISA, the only exceptions are the insurance plans for government workers.
Though difficult, patients can still sue HMOs if they were denied medical care or medications. The two major malpractice claims related to HMOs include denied care and failure in care by the primary care physician.
HMOs require their members to have a primary care physician to act as the head caretaker for the patient. This means that patients need to visit their primary care physician for any and every medical condition. The primary care physician will provide diagnosis and treatment if they can, and if not, will refer the patient to a specialist. It is the responsibility of the HMO and the primary care physician to make sure that the primary care physician has a proper patient load and the resources and knowledge to provide medical care or guidance to the patient. It is also the duty of the HMO and primary care physician to make sure that the patient is referred to another doctor when the primary care physician lacks the knowledge, skill, or resources needed to treat a patient.
Examples of malpractice related to HMOs include:
- A patient who is denied a medication by their HMO plan, and uses another medication that causes injury
- A patient whose condition worsens as a direct result of denied care
- A primary care physician failing to refer the patient to a specialist
- A primary care physician fails to refer the patient to a doctor or facility outside of the HMO network when needed
- Any physician working with an HMO fails to order necessary diagnostic tests for the patient
- An HMO member patient faces a delayed or missed diagnosis
Injuries to the Patient
If a patient suffers a serious injury as a result of an HMO’s negligence, patients can collect monetary damages for medical treatment, pain and suffering, lost wages, and in some cases, punitive damages. An experienced medical malpractice attorney can help you figure out if you or a loved one suffered negligence at the hands of an HMO or an HMO healthcare professional.