Q. Can you suggest how to proceed when we encounter patients with conditions for which a third-party payer refuses approval or payment for care?
A. The medical/legal experts emphasize that in situations when it’s financial considerations versus clinical judgment, the basic patient /physician relationship and physicians’ duties to patients remain the same. Don’t let finances or mandates levied by third-party payers alter or impact your actions on behalf of your patient.
Despite the fact that administrative control has an increasing influence on physicians in today’s health care environment, a physician’s responsibility to act for his or her patient remains paramount.
ProAssurance risk management consultants offer the following tips to safeguard patient/physician relationships and handle third-party payer situations:
- Inform the patient of the reasons supporting the recommended tests or procedures and the risks attendant to foregoing them.
- Notify the patient that the third-party payer(s) refused to pay for the tests or procedures and the patient may be financially responsible. Inform the patient of the appeals procedures available to both physician and patient.
- Follow all necessary appeal mechanisms available for physicians.
- Encourage the patient to follow all necessary appeal mechanisms as well.
- If all appeal mechanisms are exhausted, explore funding alternatives with the patient and/or assist the patient in seeking medical care elsewhere. Act as a patient advocate to exhaust all avenues for assisting the patient in obtaining necessary medical care.
- Document all these discussions thoroughly in the chart to fulfill your ethical obligation and minimize your liability exposure in utilization review decisions.
- Make clear your recommendation and role as the patient advocate are not affected by whether or not there is coverage available from the third-party payer(s).
Physicians should also document any assistance given to patients in obtaining coverage for medical treatment. For example, if you write a letter to a third-party payer, send a copy to the patient and place a copy in the patient’s medical record.
Physicians insured by ProAssurance may contact the Risk Management department for prompt answers to liability questions by calling (800) 292-1036 or via email.