TEXAS: Suspends Doctor’s License Over Denial of Care
Texas' top medical regulators have voted to suspend the license of Dallas-based UnitedHealthcare's medical director for improperly denying care to a child with a critical respiratory condition -- the first such suspension of an HMO's chief physician in the United States, according to the Dallas Morning News. The child, who died in September 1998, had been discharged from Ft. Worth-based Cook Children's Medical Center following his doctor's recommendation that he be placed on a ventilator and provided with nursing care at home. The United medical director denied the recommendation after determining that the nursing care was custodial in nature and not covered by the insurance plan. The boy ultimately received the care through the family's secondary insurance carrier, but his father filed a complaint with the state Board of Medical Examiners, saying his son would have died even earlier if the family had not had secondary coverage.
United last month filed suit in federal court to challenge the regulators' move, arguing that because the medical director made a benefit determination not a medical decision both he and United are protected by ERISA, the 1974 federal law that creates a uniform standard for regulating health plans. The insurer's lawyer explained, "We do not believe that the [state] board has the authority to act as they have." The expected court ruling will likely have significant implications for medical directors' decisions and the willingness of HMOs to deny care, the Morning News asserts. Texas Medical Association lobbyists said that the case should send a clear signal that HMO medical directors are responsible for their decisions, but a spokesman for the American Association of Health Plans stated that a ruling against United would have a "chilling effect" on medical directors and on physicians' "willingness to take on those positions." In their Feb. 22 ruling, regulators said they would put the suspension on hold if the medical director agreed to a two-year probation, 12 hours of medical courses, a $5,000 fine and other provisions. No punishment has been imposed pending the outcome of the lawsuit (Ornstein, 4/16).