Medical expert witnesses are called to testify when patients file lawsuits against physicians or HMOs alleging that capitation played a causal factor in medical malpractice. In Physicians Win Lawsuits Over Inadequate PMPM Rates, Capitation Management Report describes two scenarios:
Non-referral to specialists:
Patients file lawsuits against physicians or HMOs because the primary care physician failed to refer, or to refer in a timely manner, the patient to a specialist. The reason for the non-referral generally cited in the lawsuit is that the doctor received a financial incentive to withhold care.
Inadequate capitation rates
Physicians file lawsuits against health plans because, they say, the low rates paid are intentionally trying to drive the doctors out of business, or that they breach their contracts in various ways.