What is Managed Care Abuse?

Explainer Video by Cohen Milstein

September 21, 2023

Has an HMO or insurance company denied or delayed coverage for a treatment your doctor recommended? If so, you may have been subjected to managed care abuse.

Has your doctor recommended care that was denied by your insurance company, such as surgery or specialist treatment? Have you tried to fill a prescription, only to have your insurance company refuse coverage or raise your co-pay? You may have experienced managed care abuse.

Denial of Care

Managed care abuse occurs when an HMO or other insurer denies or delays crucial doctor-prescribed care, breaching its obligations. Managed care abuse violates both the law and the insurer’s own healthcare policy.

For instance, an insurance company may deny patient claims multiple times before finally approving them. Such delays may lead to physical harm, including the exacerbation of a physical condition that has not been properly treated. It may also cause emotional pain and suffering.   

If you have been subjected to managed care abuse, you may have a valid legal claim against your insurance company. Before you seek legal counsel, though, you must appeal the company’s decision through its internal appeals process.

Appeals of Insurance Company Decisions

Your company’s internal appeals process should be clearly defined in your insurance policy. Each appeals process is unique and subject to specific deadlines and communication requirements.

Make sure you understand why your claim was denied. This information will be in the Denial of Care letter or Explanation of Benefits form you received from your insurance company. Are your ailments and treatments accurately reflected? A denial could be due to a medical coding error that can be corrected through the appeals process.

Always document your calls and record your call reference number.  Keep copies of all important documents, including:

  • Denial letters
  • Doctors’ referrals
  • Notes of calls with insurance company representatives

Also, know what resources are available. The U.S. Department of Health & Human Services provides guidance to help you navigate the appeals process. State healthcare insurance consumer assistance programs may also assist.

Managed Care Abuse Litigation

If you’ve exhausted the appeals process without your claim being resolved, you may bring a lawsuit against your insurer. Cohen Milstein has extensive trial experience in this challenging area of law, representing patients with the most egregious claims.

Previously, our attorneys tried Chipps v. Humana, one of the country’s most influential managed care abuse lawsuits. We uncovered widespread corruption at Humana impacting its patient approval process. This discovery that ultimately resulted in stricter healthcare industry regulations. We’ve represented clients against many other major insurance companies in state and federal courts. Through the courts, we’ve helped patients receive just compensation and put a stop to managed care abuse.

Do you believe you’ve been subject to an improper denial or delay of medical care? If so, please use the CONTACT US box below to discuss your potential claim. We represent clients on a contingency basis and only receive a fee if we win your case.