Legal Issues Raised by Private Review Activities of Medical Peer-Review Organizations

Hastings, Douglas A.

doi:10.1215/03616878-8-2-293

Journal of Health Politics, Policy and Law

1983

DOI: 10.1215/03616878-8-2-293

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Legal Issues Raised by Private Review Activities of Medical Peer-Review Organizations

Douglas A. Hastings¹

Abstract: Increasingly, medical peer-review organizations are entering into contracts with insurance companies and self-insured employers to conduct utilization reviews and quality-of-care assessments. Such private review activities raise new legal issues, requiring analysis of state law as well as federal law. This paper analyzes several of the most important of these legal issues, and suggests some directions for peer-review organizations to take in order to avoid unnecessary legal problems.

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Peer Review Organizations

1985

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The Health Care Financing Administration has contracted with 54 peer review organizations (PROs) to monitor hospital use and quality of care for Medicare patients. PROs promised reductions in readmissions, in "unnecessary" admissions or invasive procedures, and in "avoidable" mortality and morbidity. A review of contract summaries for 49 PROs revealed wide variations in reduction targets. In attempting to meet their goals, PROs will encounter numerous potential pitfalls, including inaccurate and incomplete discharge data, inadequate descriptors for the variety of patients and physicians' management plans, honest differences in judgments about patient care, and limited research on the criteria used to set their reduction targets as well as the means to accomplish them. Despite having more explicit quality-of-care objectives, PROs, like PSROs (professional standards review organizations) before them, are more likely to be seen as agents of cost containment than of quality assurance. Both their credibility and their effectiveness might be enhanced if an expert panel of clinicians and health services researchers were established to help them set and achieve reasonable objectives for quality of care.

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Peer Review Organizations

1985

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A Successful Approach to the Start up of a Mental Health Case Management Program

Lizanich-Aro¹,

Goldstein²

1988

Quality Assurance and Utilization Review

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The authors have worked in the mental health uti lization review and quality assurance field for several years now. One author (S.L.-A.) has been involved in the start up of several case management and utiliza tion review programs. Their approach has been to assess existing techniques for case management and utilization review and to draw from the most effective methods and programs in the development of their own mental health case management program.

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Legal Issues Raised by Private Review Activities of Medical Peer-Review Organizations

Cited by 2 publications

References 0 publications

Peer Review Organizations

Peer Review Organizations

A Successful Approach to the Start up of a Mental Health Case Management Program

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