Medical-Legal Advice on Dealing with Insurance Denials

March 6, 2010 in Medical Legal by RangelMD

I’m not a lawyer – though I play one on TV – so take this with a grain of salt.

In my travels, I have come across many an irate physician who enthusiastically inscribes their opinion upon the official and legal record of a patient’s chart regarding the denial by the patient’s insurance of a test or procedure.

While it is perfectly acceptable and appropriate for the physician to write a note in the chart explaining the reasons for the requested test or procedure, it is almost always not a good idea to express one’s opinion about a denial in the chart. For one, a denial by an insurance company is based on medical information (which may be incomplete or inadequate) and contrary to liberal belief, this is not the insurance company practicing medicine because the decision is about what will be reimbursed and not what will be ordered.

This distinction is important because an insurance denial does not substitute for nor remove a physician’s obligation to care for the patient despite the financial barriers that the patient faces. So if a physician writes in the chart that the insurance company is threatening the life and well-being of the patient by denying a test or procedure then that physician better find a way to get it done, continue to advise the patient to have it done, or do it anyway if able. Doctors cannot transfer the medical liability for a bad outcome from themselves to the insurance company.

Of particular importance is when a physician is able to perform a test or procedure themselves and deems it necessary and states it thus in the chart but does not do so because reimbursement is denied by the insurance company. I.e. if you call the actions of the insurance company “unethical” for denying a procedure that you normally perform and recommend for your patient, don’t be surprised when a court of law uses your own words to describe YOUR ACTIONS in refusing to perform a necessary procedure unless reimbursement is guaranteed.

Nuf, said.

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