Patients who receive care through a Health Maintenance Organization, or HMO, generally expect that the doctors, hospitals, and other healthcare professionals in the plan’s network will provide appropriate medical care. When a preventable medical error causes serious harm, questions may arise about who was responsible and whether the patient has a medical malpractice claim under Georgia law.
It is important to distinguish between medical negligence by an individual healthcare provider and potential wrongdoing by the HMO itself. A doctor, nurse, hospital, pharmacy, or other provider may be responsible for negligent medical treatment, while the HMO’s role may involve issues such as provider-network oversight, authorization decisions, access to care, or care coordination.
This article explains common forms of medical negligence that may occur in healthcare delivered through a Georgia HMO network and the legal issues patients may need to consider when serious harm occurs.
What Is Medical Negligence?
Medical negligence generally involves a healthcare professional failing to exercise the degree of care and skill required under the circumstances.
A poor outcome, complication, or unsuccessful treatment does not automatically mean malpractice occurred. A viable medical malpractice claim generally requires evidence that:
- The healthcare provider owed the patient a professional duty of care
- The provider failed to meet the applicable standard of care
- That failure caused or contributed to the patient’s injury
- The patient suffered damages as a result
When treatment is delivered through an HMO network, the investigation may also need to examine whether decisions made by the health plan affected access to appropriate care.
What Role Does a Georgia HMO Play?
HMO stands for Health Maintenance Organization. An HMO is a type of managed health plan that generally arranges healthcare through a network of participating physicians, hospitals, and other providers.
The HMO may be involved in:
- Developing and maintaining a provider network
- Credentialing participating providers
- Utilization review
- Authorizing certain services
- Coordinating referrals
- Maintaining quality-assurance procedures
Georgia requires HMOs seeking authority to operate to have arrangements for an ongoing quality-of-care assurance program. That does not mean the HMO is automatically liable whenever a network provider commits malpractice, but the organization’s own actions can become relevant depending on the facts.
Misdiagnosis and Delayed Diagnosis
A diagnosis can be missed or delayed for many reasons, and not every diagnostic error constitutes malpractice.
A potential claim may exist when a reasonably careful healthcare provider should have recognized the need for additional testing, referral, or treatment and the delay caused additional harm.
Examples may involve:
- Failure to diagnose cancer
- Failure to identify a heart attack or stroke
- Failure to diagnose infection
- Failure to recognize a blood clot
- Failure to order appropriate follow-up testing
In an HMO setting, access or referral issues may also need to be examined if the patient could not obtain timely specialist care or diagnostic testing.
Medication Errors
Medication mistakes can occur at several points in the healthcare process.
Examples may include:
- Prescribing the wrong medication
- Prescribing an incorrect dose
- Failing to identify a dangerous drug interaction
- Administering medication to the wrong patient
- Failing to account for a known allergy
- Failing to communicate medication changes between providers
Responsibility may rest with a physician, nurse, pharmacist, hospital, or another healthcare provider depending on where the error occurred.
Surgical and Procedural Errors
Surgical complications can occur even when proper care is provided. Medical negligence involves more than the fact that a patient experienced a poor outcome.
Potential surgical malpractice issues may include:
- Wrong-site surgery
- Wrong-patient surgery
- Retained surgical objects
- Anesthesia errors
- Failure to respond appropriately to surgical complications
- Failure to provide appropriate postoperative care
The question is whether the surgeon, anesthesia team, hospital, or other provider failed to meet the applicable standard of care and whether that failure caused injury.
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Birth Injuries
Birth injuries can arise from many causes, including complications that could not reasonably have been prevented. The presence of an injury does not automatically mean that an obstetrician, nurse, hospital, or other provider was negligent.
Potential malpractice issues may involve:
- Failure to appropriately monitor fetal distress
- Delay in performing a medically indicated cesarean delivery
- Improper management of shoulder dystocia
- Failure to diagnose or treat maternal infection
- Improper use of forceps or vacuum-assisted delivery
- Failure to provide appropriate neonatal treatment
If an HMO authorization or referral decision allegedly delayed necessary obstetrical or neonatal care, that issue may require separate investigation.
Failure to Refer to an Appropriate Specialist
Some medical conditions require evaluation by a specialist.
A potential negligence issue can arise when a treating provider fails to refer a patient despite symptoms or findings that reasonably call for specialist evaluation.
In an HMO setting, the investigation may also examine whether:
- The referral was requested
- Authorization was delayed or denied
- An appropriate specialist was available in the network
- The patient was given a medically appropriate alternative
Whether a delay amounts to negligence depends on what care was medically necessary and whether the delay actually caused harm.
Failure to Follow Up on Test Results
Diagnostic testing is useful only if important results are reviewed and acted upon.
Potential problems may include:
- Abnormal lab results not being reviewed
- Imaging findings not being communicated
- Failure to notify the patient of significant findings
- Failure to arrange appropriate follow-up testing or treatment
A breakdown can occur within an individual medical practice, between providers, or during transitions between facilities.
Emergency Care Delays
Patients experiencing serious symptoms may require immediate treatment rather than routine authorization or referral processes.
When an emergency-care delay causes harm, an investigation may examine the conduct of healthcare providers as well as any plan-related procedures that affected access to care.
The applicable legal standard can depend on the nature of the emergency treatment involved, so these cases should be evaluated based on their specific circumstances.
Inadequate Communication and Care Coordination
HMO patients may receive care from multiple network providers, including a primary care physician, specialists, diagnostic facilities, hospitals, and pharmacies.
Communication failures may result in:
- Missing test results
- Duplicated or conflicting medications
- Incomplete medical histories
- Missed referrals
- Failure to schedule necessary follow-up care
A care-coordination problem becomes a legal issue when the evidence shows that a responsible provider or entity failed to meet a legal duty and that failure caused the patient’s injury.
Negligent Provider Selection or Oversight
Because HMOs maintain provider networks, questions can sometimes arise about how a provider was credentialed or retained in the network.
Potential issues may include whether appropriate procedures were used to verify professional qualifications, licenses, or other information relevant to network participation.
This is different from a medical malpractice claim against the individual physician. Any claim directed at the HMO itself would require evidence supporting a separate legal basis for holding the organization responsible.
Can an HMO Be Held Responsible for Medical Negligence?
An HMO is not automatically responsible simply because the allegedly negligent doctor or hospital participated in its network.
Potential liability depends on the facts and legal relationships involved.
A case may require examination of:
- Who made the allegedly negligent medical decision
- Whether the provider was employed by or independent from the HMO
- Whether an HMO authorization or coverage decision affected treatment
- Whether provider-network or credentialing conduct played a role
- Whether federal or state law affects a claim directed at the health plan
For that reason, a case involving treatment obtained through an HMO should not automatically be described as an “HMO malpractice case.” The evidence must identify who actually caused the harm and what legal duty that party owed.
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Evidence That May Be Important in an HMO-Related Medical Negligence Case
The medical records are often only part of the evidence when treatment was coordinated through a managed care plan.
Potentially relevant materials may include:
- Hospital and physician records
- Laboratory and imaging results
- Referral requests
- Prior-authorization records
- Coverage or denial notices
- Appeal records
- Communications between the provider and the HMO
- Plan documents
- Provider-network information
These records can help distinguish between a treatment error by a medical provider and a separate managed-care decision that may have affected the patient’s treatment.
Georgia Medical Malpractice Claims Usually Require Expert Review
Determining whether medical negligence occurred generally requires more than reviewing the patient’s outcome.
Qualified medical professionals may need to evaluate what care should have been provided, what actually occurred, and whether the alleged error caused the patient’s injury.
Georgia also generally requires a professional-malpractice complaint to include an affidavit from a qualified expert identifying at least one negligent act or omission and the factual basis for the allegation, subject to limited statutory exceptions.
How Long Do You Have to File a Georgia Medical Malpractice Claim?
Georgia medical malpractice claims are subject to strict filing deadlines.
Georgia generally provides a two-year limitations period for an injury or death resulting from a negligent or wrongful medical act or omission and generally imposes a five-year statute of repose measured from the alleged negligent act or omission. Different rules and exceptions can apply in particular cases.
Claims involving health plans can also raise additional legal questions depending on the plan and the theory of liability. The applicable deadlines should therefore be evaluated based on the specific facts rather than assumed.
How a Medical Negligence Attorney Can Help
When a patient suffers serious harm while receiving treatment through an HMO network, an attorney can help determine which individual or organization may be responsible.
That investigation may involve:
- Obtaining and reviewing medical records
- Obtaining referral and authorization records
- Identifying the providers involved
- Reviewing the HMO’s role in the patient’s care
- Consulting qualified medical experts
- Evaluating whether the standard of care was breached
- Determining whether the alleged conduct caused additional injury
- Evaluating applicable Georgia filing requirements
Contact Keenan Law Firm About Medical Negligence in Georgia
If you or someone you love suffered a serious injury while receiving care through a Georgia HMO network, it may be necessary to investigate both the medical treatment provided and the role of the health plan in coordinating or authorizing care.
At Keenan Law Firm, we can review the medical records, referral and authorization history, identify the healthcare professionals and organizations involved, work with qualified medical experts, and evaluate whether the evidence supports a medical negligence claim under Georgia law.
The fact that a healthcare provider participates in an HMO does not automatically make the HMO responsible for that provider’s conduct. A careful investigation can help determine where the alleged failure occurred and which parties may be legally responsible.
Contact Keenan Law Firm to discuss the circumstances of your care and learn more about the legal options that may be available.