Health Care: Antitrust Issues Relating to Physicians and Third-Party Payers

HRD-91-120: Jul 10, 1991

Additional Materials:

Contact:

Office of Public Affairs
(202) 512-4800
youngc1@gao.gov

Pursuant to a legislative requirement, GAO reviewed physician antitrust issues, focusing on: (1) the effect of antitrust laws on physicians' ability to act in groups to educate and discipline peers to reduce and eliminate ineffective practices and inappropriate utilization; and (2) how such issues relate to third-party payers' adoption of practice guidelines.

GAO found that: (1) the Supreme Court did not decide whether the medical profession constituted trade or commerce until 1975, when it ruled that the Sherman Antitrust Act applied to professionals; (2) the Court found that maximum fee schedules setting the maximum fee physicians could claim in full payment for services provided to policyholders of certain insurance plans violated the act; (3) hospital peer review is subject to antitrust scrutiny and is likely to violate the law only when physicians abuse the process; (4) if physician groups produce guidelines solely for informational purposes, there is little chance of an antitrust violation; (5) under recent legislation, physicians serving Medicare patients will receive payment for medical services based on the lesser of actual charges or a statutory fee schedule; (6) a monetary conversion factor may provide physicians an incentive to limit current Medicare expenditures to maintain the rate of reimbursement in subsequent years; (7) a judicial doctrine protects physicians from antitrust liability efforts by private entities to obtain or influence government legislation or regulations; (8) it was difficult to determine whether third-party payers adopting practice guidelines to determine which claims they would reimburse would qualify under a law exempting state-regulated business of insurance from the Sherman Act, but insurers could independently adopt guidelines; and (9) at present, there appears to be no need for legislation providing antitrust immunity to physicians or payers to facilitate peer review activities.

Oct 19, 2017

Oct 18, 2017

Oct 17, 2017

Oct 13, 2017

Looking for more? Browse all our products here