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With Insurers, Appeals are Best Policy |
Many physicians today feel that health care insurers interfere with the physician/patient relationship when they refuse to pay for physician recommended medical services. And while insurers wield "veto power" over some clinical decisions, they are protected from liability when treatment non-approvals are linked to adverse medical outcomes.
Unfortunately, the fact that insurers cannot be sued for treatment non-approvals makes physicians even larger targets for malpractice litigation. When health insurer decisions conflict with a physician's medical judgment, the physician must advocate on the patient's behalf, both for the patient's health, and to stay out of the courtroom.
This point was made clear in a 1987 Appellate Court decision regarding Wickline vs. State of California. In that case, a vascular surgeon requested an eight-day hospitalization extension for a Medi-Cal patient recovering from an aorto-femoral graft. A Medi-Cal physician consultant reviewing the request approved only four days. The surgeon did not appeal Medi-Cal's decision. Once home, the patient developed a blood clot and a severe infection, resulting in emergency hospitalization and above-the-knee amputation. The patient sued Medi-Cal for negligent discharge from the hospital.
During the trial, the surgeon testified that he believed that Medi-Cal had the power to tell him when the patient should be discharged from the hospital. He thought that his "hands were tied" regarding the four-day hospitalization decision, because it came from a physician who reviewed treatment approvals on behalf of Medi-Cal. Consequently, he felt that protesting or appealing the decision was an exercise in futility.
After an initial decision against the state, attorneys for Medi-Cal appealed, arguing that determining what treatment is medically necessary for patients is ultimately the physician's responsibility. The Appellate Court agreed, ruling that physicians are ethically obligated to use their medical judgment to advocate for a patient's health. Because the physician did not utilize Medi-Cal's appeals process, he was essentially compliant with Medi-Cal's hospitalization decision.
In Illinois, the Managed Care Reform and Patient Rights Act (MCPRA) specifically encourages physician advocacy for "appropriate health care services" for patients. At the same time, the Act prohibits health plans from retaliating against physicians who appeal payment denial decisions. When faced with payment denials for health care services, physicians should make full use of the plan's appeals process. While appealing does not guarantee that a health plan will reverse a payment decision, it can serve to remind the patient that the physician is the "patient's ally" - a role that leads to increased patient satisfaction and decreased litigation.
When a health plan issues a denial of payment for medical services:
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Advise the patient about the treatment recommendation.
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Inform the patient that the managed care entity has refused to cover treatment that, in your medical opinion, is necessary.
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Protest, following the plan's appeals procedure. In some cases, it may help to "escalate" the appeal to a supervisor or medical director.
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Document that you discussed the situation with the patient, and are using the plan's appeals mechanism to protest their decision.
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Assist the patient in finding alternative care, if appropriate.