DOCTOR'S VIEWS ARCHIVE

ERISA, HMO, MCO, NCQA....Getting Through The Legalities & Alphabet Soup Of Managed Health Care

(August 2, 1998) Over the last few weeks there has been much in the news regarding various federal plans to "improve" the present Managed Health Care System in the U.S. This has been fueled in large part by the virtual explosion of Health Maintenance Organizations (HMOs) and other types of entities that now manage the health care of most of our citizenry.

The sudden impact of this "new" health industry, has also lead to much confusion among plan participants as to what and what may not be covered in their plans, and to accusations of fraud and abuse.

How does one pick a good, reliable health plan, and judge its performances in comparison to others? What are the legal recourses, if any, if the plan does not deliver proper medical care?

Only an informed individual can make reasonable judgments as to how the present debate in Congress should end, and which of the diverse fixes to the health care system should be enacted. In addition, only a well-informed individual who has done the appropriate research can decide which Managed Care Plan, if any, is right for them. And finally, only a well-informed and well-educated patient will be aware if the level of medical care they are receiving meets present standards. This last issue is extremely important given the presently debated issue regarding a patient's right to sue their Managed Care Organization (MCO).

So here are some basic facts and guides as to where you can find sources to make these decisions, just in time to bug your government representatives about these issues:

THE PRESENT HEALTH CARE LEGISLATION:

There are two proposals up before Congress - Democratic and Republican versions.