Joseph Romano Law

Catastrophic Illness and Injuries

PRESENTER:	JOSEPH L. ROMANO, ESQUIRE
SUBJECT:	IN-SERVICE
WHEN:	WEDNESDAY, JUNE 2, 1999 - 1:30 TO 3 PM
WHERE:	CONFERENCE ROOM #1
CONTACT:	MARGARET HINDERLITER, DIRECTOR OF SOCIAL WORK

Treatment or Practice Guidelines: Recovery Recommendations or Treatment Barriers?
1. What are the treatment/practice guidelines?
2. Purpose
3. Pros and Cons
  1. Providing estimates of optimal recovery
  2. Predicting complications a patient may experience
  3. Limits flexibility of treating professionals
  4. Recovery recommendations vs. Treatment Barriers
Examples of Restrictive Guidelines
1. Unfair and unnecessary medical documentation - reconstructive surgery
2. Overly restrictive guidelines: i.e. requesting unrealistic progress before extension of burn rehab stay
Problems with Treatment or Practice Guidelines
1. The guidelines are published by health care management agencies, and vary from company to company
2. The guidelines are written so they are open to HMO interpretation
3. HMO guidelines are not provided to the insured, the insured's treating doctor or other health care professionals
4. Insurance companies modify the guidelines or restrict the guidelines according to their business needs
5. Guidelines adopted by HMOs vary significantly from insurance plan to insurance plan
Aggressive Managed Care Practices to Enforce Treatment or Practice Guidelines
1. Peer review
2. Precertification and the appelate process
3. Roadblocks to deny or limit coverage (Medical necessity vs. Cosmetic surgery)
4. Referal or no referral to a specialist in the HMO system/non-participating facilities
5. Release of medical information: Are patients at risk?
Weapons to Defeat Restrictive Treatment/Practice Guidelines
1. Appeals
2. External reviews
3. Bad Faith
4. Suits and Legislation