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 always expressed during my years in residency training and even now, as a private practice hospitalist, I hear misinformation being spread day in and day out
This myth is perpetrated by doctors, nurses, and therapists of all kinds. What is this myth? Health insurance companies will not pay for the care provided if you, the patient, want to leave against the medical advice of your 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. Medical necessity is the threshold for payment. If the services you have already received were medically necessary, whether you choose to stay or leave is irrelevant with regards to the services you have already received.
Look at it from a different perspective. If you go to the emergency room 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 is medically necessary, your care will be paid for whether you leave the hospital when your physician believes it is safe or not.
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. Medical necessity is the threshold for payment. If the services you have already received were medically necessary, whether you choose to stay or leave is irrelevant with regards to the services you have already received.
Look at it from a different perspective. If you go to the emergency room 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 is medically necessary, 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 would dare exist, third parties 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 at any time, including refusing further hospitalized care at the recommendation of our physician.
When you enter a general medical hospital, you are doing so under your own free will. Since you voluntarily agree 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. 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.
It's time for health professionals to stop creating such anxiety for our patients. Our hospitals are not prisons. As physicians, we do not hold our patients hostage against their will. If our patient wants to leave, they have a right to leave, and their insurance will pay for all care up to that point in time. In fact, physicians can and should submit a bill for payment when discharging patients against medical advice. As a physician or nurse, 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. It is the physician's responsibility to verify their patient has the capacity to make their own medical decisions, no matter how poor that decision is.
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 an appropriate 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)
