Law Note: Social Workers, Managed Care, and Antitrust Issues
by:
Denise Diaz, Esq., Paul H. Friedman, Esq., and Carolyn Polowy, Esq.
Published: April 1997 ©NASW
Pages: 10, including appendix
Overview
Managed care organizations (MCOs), in conjunction with employers who provide employment-based health insurance programs, play a large and growing role in the health care options made available to health plan participants. MCOs have been placed in positions of bargaining strength vis-à-vis social workers as providers of mental health care or other covered services.
Federal and state antitrust laws are being used by other health care professionals to challenge MCO practices that limit or interfere with the right to practice, to be members of provider panels, and to make appropriate decisions on behalf of their patients. Social workers should understand the issues and arguments raised in antitrust health care cases to be able to evaluate the business practices of the MCOs with which they are dealing.
To assist social workers in these efforts, this law note describes federal antitrust laws, the type of conduct that could be actionable under those laws, and health care cases in which MCO conduct is being challenged as violating antitrust laws.
This note identifies the steps that might be taken by social workers to evaluate their own fact situation under antitrust laws, including obtaining assistance from federal and state antitrust authorities, state insurance regulators, state legislatures, and Congress. Finally, precautions that should be observed by social workers in their work and as NASW members to minimize their own risk of antitrust liability are reviewed. A sample protest letter to an MCO is also included (Appendix A).