If a managed care plan won't authorize a referral or advance tests on the basis of established medical practice guidelines, but makes policy primarily on financial grounds, it's asking for trouble, he warns. Neil B. Caesar says that as a rule, managed care adds a new layer of malpractice exposure for physicians. The extent to which exposure increases is just beginning to become clear, Caesar believes. And working under managed care restrictions doesn't take the physician off the hook in terms of liability, either. When a physician believes a denial is based on cost rather than clinical quality, the physician should not adhere to the managed care party line.
Physicians have an obligation to pursue the patient's clinical requirements.
The fact that the managed care plan has another set of priorities does not excuse the physician from responsibility. Even with the development of clinical guidelines and protocols, it's unlikely all risk will be eliminated. There are never going to be enough clinical guidelines to cover every situation. Still, the situation is improving. As guidelines proliferate, they're going to have evidentiary value in malpractice actions.