When courts review medical appropriateness.
When courts review medical appropriateness.
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当法院审查医疗适当性时。
DOI：
10.1097/00005650-199808000-00016
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发表时间：
1998
期刊：
影响因子：
3
通讯作者：
Smith,TR
中科院分区：
文献类型：
--
作者：
Anderson,G;Hall,MA;Smith,TR
目的：作者研究了法院如何回应公共和私人保险公司的医疗适当性标准，以建立覆盖面和支付policies.Methods.A结构性审查所有联邦和州法院的健康保险案件决定在1960年和1994年6月之间，涉及医疗适当性的争议进行。共有3，215份已公布的法院判决进行了分析，其中203份符合相关性标准，124份明确提到医疗适当性标准。主要的结果变量是法院是否命令保险公司提供coverage.Results。在185例中，一个明确的决定被提出，和保险公司被要求支付的决定的57%。保险人是否依赖评估，评估过程是正式的还是非正式的，以及谁进行了评估，似乎都不会影响法院的裁决，承保范围排除的具体性也不会影响法院的裁决。法院下令覆盖的显着预测法院管辖权，合同语言分配自由裁量权的保险公司，病人的病情的严重程度，以及是否出现的治疗工作的特定patient.Conclusions。为实践指南被法院接受，更重要的是把重点放在如何写保险合同比如何进行医疗评估。
Objectives.The authors examined how the courts have responded to public and private insurers' use of medical appropriateness criteria to establish coverage and payment policies.Methods.A structured review of all federal and state court health insurance cases decided between 1960 and June 1994 that involved a dispute involving medical appropriateness was performed. A total of 3,215 published court decisions were analyzed, of which 203 met the criteria of relevance and 124 explicitly mentioned medical appropriateness criteria. The main outcome variable was whether the court ordered the insurer to provide coverage.Results.In 185 cases, a definitive decision was rendered, and the insurer was required to pay in 57% of the decisions. Whether the insurer relied on an assessment or not, whether the assessment process was formal or informal, and who conducted the assessment did not appear to influence courts' decisions, nor did the specificity of the coverage exclusion. Significant predictors of courts ordering coverage were court jurisdiction, contract language assigning discretion to the insurer, severity of patient's condition, and whether the treatment appeared to work for the particular patient.Conclusions.For practice guidelines to be accepted by the courts, it is more important to focus on how insurance contracts are written than on how medical assessments are performed.