What are the legal implications of managed care?

Managed care is a type of health care system that attempts to balance cost and quality of care by having providers coordinate care and managing the health care of a particular population. In Texas, managed care organizations (MCOs) are regulated through the Texas Health and Human Services Commission (HHSC). When a patient enrolls in an MCO, the MCO assumes responsibility for the patient’s care and agrees to pay for it in exchange for a fee from the patient or the patient’s insurer. Thus, an MCO’s legal responsibility for providing care becomes a contractual obligation that must be met. An MCO must adhere to the terms of the contract, which usually includes providing certain types of care, providing quality of care, and preventing fraud and abuse. The HHSC also sets standards for MCOs to ensure quality of care, and MCOs must comply with these standards or risk penalties from the state. The HHSC also requires MCOs to submit annual reports and undergo periodic on-site reviews to ensure compliance. Managed care can also have legal implications for providers as well. MCOs typically enter into contracts with providers that limit the types of services the providers can offer and the fees they can charge, and providers must comply with these contracts or risk termination of their contract and loss of payment. Thus, providers must consider the contractual obligations of any managed care plan when determining whether to accept a particular patient. Overall, managed care has been successful in helping to control costs and improve the quality of care while still allowing for flexibility in providing services. It is important to understand the legal implications of managed care both for providers and for patients who are enrolled in MCOs in order to ensure that the rights of all involved are protected.

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What are the legal implications of managed care?

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