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What to do when it’s financial considerations versus clinical judgment
e-Reports, Feb. 6, 2012
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ProAssurance offers risk management recommendations to help you with equipment, resources and discharge planning. Untitled document

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.

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