United States Government Publishing Office publisher pbl distributor dst United States Government Accountability Office Health, Education, and Human Services Division author aut Government Organization text government publication eng GAOREPORTS Legislative Agency Publications gao legislative 2010-08-12 U.S. Government Printing Office 1998-07-13 monographic deposited born digital 62 p. GA 1.13:HEHS-98-154 https://www.govinfo.gov/app/details/GAOREPORTS-HEHS-98-154 P0b002ee18038ea89 f:he98154 DGPO 2010-08-12 2011-03-28 GAOREPORTS-HEHS-98-154 machine generated eng fdlp REPORT GAOREPORTS-HEHS-98-154 HEHS-98-154 Managed health care Litigation Consumer protection Damages (legal) Liability (legal) Eligibility determinations Proposed legislation Malpractice (medical) Employee medical benefits Letter Report HEHS

Pursuant to a congressional request, GAO reviewed how people enrolled in employer-based managed care plans are compensated when they are improperly denied health care benefits or when they experience negligent medical care and the role that the Employee Retirement Income Security Act (ERISA) plays, focusing on: (1) whether the transition from traditional employer-based fee-for-service health plans to managed care has changed the process of benefit determination; (2) the remedies that ERISA provides to participants in employer-based managed care plans who are improperly denied benefits; (3) whether ERISA affects the ability of participants to be compensated for injuries that result from either medical malpractice or improper benefit denials at employer-based managed care plans; and (4) the consequences of changing ERISA's remedies.<p/>GAO noted that: (1) managed care plans attempt to ensure that enrollees receive services that are necessary, efficiently provided, and appropriately priced; (2) since the 1980s, employers have shifted to offering managed care plans that use such techniques as prospective utilization review (UR); (3) as a result, benefit coverage decisions have increasingly shifted from being made after services are provided to before; (4) ERISA effectively limits the remedies available when employees of private-sector firms claim to have been harmed by plans' decisions to deny coverage of a particular service; (5) under ERISA, plans must have an appeal process for participants who are dissatisfied with a benefit denial; (6) if participants are not successful, they can file a civil lawsuit; (7) ERISA's exclusive remedy for improper benefit denials is to require the plan to provide the denied service and, at the court's discretion, pay attorney fees; (8) groups representing consumers believe that ERISA's limited remedy neither provides sufficient compensation for injuries that benefit denials contribute to nor effectively deters unjustified benefit denials; (9) ERISA can affect participants' ability to be compensated for injuries sustained while in an employer-based health care plan; (10) ERISA's preemption of state laws that relate to employee health benefit plans enables managed care plans and UR firms to avoid liability under state law for medical malpractice; (11) compelling evidence is lacking on the likely effects of amending ERISA to provide either expanded remedies for losses due to disputed benefit denials or the ability to sue managed care plans for medical malpractice under state tort laws; (12) consumer groups and others assert that additional remedies could: (a) improve health care quality by holding plans accountable for the consequences of their benefit coverage decisions; and (b) provide participants with a course of remedies more comparable to state tort laws; (13) managed care plan and employer groups maintain that these additional provisions would result in increased costs or benefit reductions; and (14) to date, data are not available to accurately estimate the extent to which the quality of health care would improve or the amount by which the costs of plans, employers, and employees might change if ERISA's remedies or preemption of state laws were amended. https://www.govinfo.gov/content/pkg/GAOREPORTS-HEHS-98-154/html/GAOREPORTS-HEHS-98-154.htm https://www.govinfo.gov/content/pkg/GAOREPORTS-HEHS-98-154/pdf/GAOREPORTS-HEHS-98-154.pdf GAO/HEHS-98-154 https://www.govinfo.gov/app/details/GAOREPORTS-HEHS-98-154 Letter Report GAO/HEHS-98-154; Employer-Based Managed Care Plans: ERISA's Effect on Remedies for Benefit Denials and Medical Malpractice; Managed health care Litigation Consumer protection Damages (legal) Liability (legal) Eligibility determinations Proposed legislation Malpractice (medical) Employee medical benefits Title 29 Section 1001-1461 Title 29 Section 1001(b) Title 29 Section 1002(1) Title 29 Section 1002(21)(A) Title 29 Section 1003(b)(1) Title 29 Section 1132(a) Title 29 Section 1132(a)(1)(B) Title 29 Section 1133 Title 29 Section 1144(a) Title 29 Section 29 29 U.S.C. 1001-1461 29 U.S.C. 1001(b) 29 U.S.C. 1002(1) 29 U.S.C. 1002(21)(A) 29 U.S.C. 1003(b)(1) 29 U.S.C. 1132(a) 29 U.S.C. 1132(a)(1)(B) 29 U.S.C. 1133 29 U.S.C. 1144(a) 29 U.S.C. 29 Title 42 Section 300eet seq. 42 U.S.C. 300eet seq. Volume 88 Page 829 88 Stat. 829 Public Law 93-406