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Health Insurance Coverage And Leaving The Hospital Against Medical Advice

There is a huge myth being unknowingly  perpetrated against the general public when it comes to their rights and responsibilities as a patient.  It’s a myth that I can remember hearing as far back as my first few weeks of clinicals during medical school.  It was a constant presence during my residency training and even now, as a private practice hospitalist I hear misinformation being handed down day after day, month after month.

This myth is perpetrated by doctors, nurses, and therapists of all kinds.  What is this myth?  That their health insurance company will not pay for the care provided if they want to leave against the medical advice of their physician.

Will my insurance company pay if I leave against medical advice (AMA)? Yes.  They will pay.  Medicare and Medicaid pay for services that are medically necessary.  For example, if you go to the ER and the doctor recommends a CT scan of your chest and you decline, this does not mean the insurance company will deny payment for your visit to the emergency room.  This is what  the informed consent process is for.  If you have been admitted for a medical condition that requires hospitalization and your care plan meets Medicare medical necessity muster, your care will be paid for whether you leave the hospital when your physician believes it is safe or not.  

Unless your insurance has a specific policy rider that states you must comply with all the recommendations of your physician, which I doubt such a policy exists, they simply do not pay based on whether you decide to agree or disagree with the plan set forth for your care.  If you have any doubt, pull out your phone and call your insurance company from your room.  As patients, we have the right to refuse the recommendations of our physicians, including refusing further advised hospitalized care.

When you enter a general medical hospital, you are doing so under your own free will.  Since you voluntarily agreed to be admitted, you have the right, at all times, to refuse any and all care being provided, including leaving the hospital against the advice of your physician.

And all the care rendered up to that point will get paid for as long as it was medically necessary.  In the last month alone I had to smooth over concerns by three patients and their families who wished to leave the hospital against the advice of their physician but were told by another health care provider that their care would not be paid for.

Our hospitals are not prisons. As physicians, we do not hold our patients hostage against their will.  If your patient wants to leave, they have a right to leave, and their insurance will pay for all care up to that point in time.    As a physician or nurse or other therapy provider with direct patient contact, it’s time we stopped perpetuating this false myth of insurance companies not paying if our patients wish to leave AMA.

If patients want to leave against medical advice, it is our responsibility to explain the risks and benefits or leaving, complete any and all necessary paperwork and follow up needs that minimize the risk to bad outcomes and discharge the patient just as we discharge all our patients and provide them with any necessary prescriptions.  Because they want to leave AMA does not absolve us of our responsibility to discharge them.  It is a patient’s right to leave, if you have verified they have the capacity to understand the risks and benefits of leaving against your advice.  That is your physician responsibility for patients leaving AMA.

If you want to release the patient from your office because of their failure to comply with a plan you have set forth and you no longer feel that you can continue in an adequate physician-patient relationship, you may release them from your practice with a fire my patient letter” after notifying them of your intentions and allowing them adequate time to find a new physician (usually 30 days).

That’s how it works.  So, for the love of God, stop telling patients their insurance won’t pay if they leave AMA.  It’s just not true.

(This is not legal advice.  Contact your lawyer if you’re looking for legal advice)

*This blog post was originally published at The Happy Hospitalist*

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2 Responses to “Health Insurance Coverage And Leaving The Hospital Against Medical Advice”

  1. D. St James says:

    I was just the recipient of a “heads up” warning that my husband’s insurance company may not pay the bill (this was medically necessary) if he discharged himself AMA. I can’t believe this hospital would be so irresponsible, or maybe I can. Thank you for your very informative article.

  2. Sebastian says:

    Thank you for this article. I just left my hospital AMA because even though all of my tests were OK and the doctor said that he was not too concerned but just wanted to keep me overnight as a precaution. It was something that could have been handled on an outpatient basis. Given some other health issues, staying overnight anywhere is not comfortable for me and so I would always prefer to be home unless it is a serious emergency. Nurses and doctors kept threatening that my insurance might not pay if I left AMA. The whole experience felt stressful, paternalistic and coercive. The sense I got was that the hospital’s main interest in the situation was to minimize their liability exposure rather than what was necessary and best for my specific situation. I eventually did leave and will never go back again.

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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