Healthcare Liability and HMOs in Massachusetts

HMOs, or Healthcare Maintenance Organizations, are a popular form of health insurance in Massachusetts and allow patients to receive this type of insurance through their employer. Healthcare Maintenance Organizations place restrictive rules on healthcare professionals that accept patients with this type of healthcare insurance and emphasize the role of a primary care physician in a patient’s overall health.

If you have suffered due to HMO negligence in Massachusetts, you may be entitled to monetary damages for the losses you have experienced. At Sweeney Merrigan Law, we have over 100 years of combined experience pursuing justice on behalf of patients who endured suffering at the hands of a medical professional’s mistakes. Call us 24/7 at (617) 391-9001 for a complimentary consultation or fill out our contact form today. 

What Is an HMO in Massachusetts?

Massachusetts Healthcare Maintenance Organizations are healthcare plans that provide health services to patients located in certain geographic areas in return for fixed payment plans. This type of coverage generally won’t cover costs associated with out-of-network providers, except in specific cases of emergency. This type of healthcare plan works to emphasize prevention and wellness. 

HMO Staff Model 

An HMO staff model is the most common model used; the organization owns the healthcare practice and employs medical professionals to work in their HMO facility. 

HMO Group Model 

The HMO Group Model involves a group of physicians contracting an HMO, allowing the healthcare professionals to treat patients with HMO and patients with other insurance coverage. 

HMO Network Model 

A Network HMO model allows HMO contracts with a number of groups of physicians that patients with HMO coverage may visit for prepaid treatment and healthcare services. 

Massachusetts Healthcare Maintenance Organizations utilize more control over their hired physicians than other healthcare plans due to the fact that they require all members to retain a primary health physician as a primary gatekeeper of their wellness and care. Patients with HMO plans typically cannot see specialists without a referral from their primary health physician. Additionally, for patients that opt for prepaid plans, HMOs remove obstacles to certain healthcare and doctors are preoccupied with concerns that patients may not be able to afford certain treatments because of the full coverage. 

Massachusetts Healthcare Liability and HMOs

Due to HMOs being an entity of the federal government covered by the Employment Retirement Income Security Act (ERISA) of 1974, they are difficult to sue for medical malpractice or Massachusetts healthcare liability. In certain states, it is permissible to pursue liability against HMOs but got resistance from the supreme court, which ruled against it. Although it is complex to sue HMOs for Massachusetts medical malpractice, it is still possible if you were denied medical care or medication. The two most common healthcare liability claims against HMOs are the following: 

• Denied medical care by a healthcare professional 
• Failure in treatment and care by the primary care physician 

Under HMO coverage, primary healthcare physicians are a patient’s main caretakers. This means that patients must seek the treatment of their primary physician for any healthcare-related reason or medical condition. If the primary health physician cannot treat the condition, only then will they refer a patient to a specialist. 

It is the responsibility of the Massachusetts Healthcare Maintenance Organizations or primary health providers to make sure that the physician has a proper patient load, resources, and knowledge to provide adequate care to patients. It is also their lawful responsibility to refer out when they lack the knowledge, resource, or skill to treat the patient sufficiently. 

Examples of Massachusetts HMO Healthcare Liability: 

• Medication denial by their HMO plan and being prescribed a different medication that causes injury
• Worsening medical conditions as a result of denied care
• Failing to refer the patient to a specialist when they didn’t have the resources or skills to adequately treat the patient 
• Failing to refer to physicians outside of the network when needed
• Failing to order necessary diagnostic tests for the patient
• A patient encountering a delayed or missed diagnosis that leads to further injury or decline in health

The Massachusetts lawyers at  Sweeney Merrigan Law are equipped with the extensive resources necessary to conduct an exhaustive investigation into the HMO medical negligence and uncover the healthcare liability that led to your substantial injuries. We have an extensive, successful record of obtaining justice for medical malpractice victims in cases just like yours. 

Speak With a Massachusetts Medical Malpractice Lawyer at Sweeney Merrigan Law 

The medical malpractice team at Sweeney Merrigan Law is composed of dedicated, seasoned, and compassionate attorneys.