180.004 Managed Care Antitrust


Managed Care Antitrust: State and federal antitrust laws should apply equally to health maintenance organizations, preferred provider organizations, and physician/hospital organizations to assure a fair framework for fair competition; that fair market practices should be required of HMOs, PPOs, and PHOs, and of all managed care organizations; that fair market practices should include basing physician credentialing quality assurance and utilization review decisions by managed care organizations on quality considerations; and that quality considerations may include physician profiling for educational purposes or to target chart review for determining medical necessity, prudent, or wasteful practices, utilizing peer review and due process (CSE, p 145, A-93; reaffirmed CSE Rep. 6-A-03; reaffirmed CSE Rep. 1-A-13).

Last Updated On

October 07, 2016