Managed Care Organizations

In this unit, you have learned about the liability of MCOs (managed care organizations) such as HMOs (health maintenance organizations) and PPOs (preferred provider organizations).

Thinking about the information in Chapter 6, where does the liability lie for the managed care organization when the MCO personnel make decisions about insurance coverage for hospital stays?

Please do not limit your analysis to length of stay, but consider other scenarios associated with MCO decision making such as approval or denial of medically necessary treatment (or limitations of treatment) as well, and share your scenarios with the class.

Defend your response thoroughly and include the potential liability implications.

Lastly, discuss the options, if any, MCO or PPO plan members have when denied coverage for medically necessary care.