Will Insurance Pay if a patient leaves AMA?
Truth or Fiction? If you leave AMA your insurance won’t pay...
Recently a patient who wanted to leave the ED was told by a clinician that if she did so, she would be responsible for the hospital charges because her insurance wouldn’t pay. She perceived this as a threat which was being used to coerce her into staying against her will. She did stay, and filed a complaint with Patient Relations about this interaction.
In investigating the complaint, Patient Relations asked the leadership of the UWHC Business Office whether this statement about charges was true. We learned that the Business Office is not aware of any claim that has been denied for this reason. In a report of discharges Against Medical Advice in the last 7 months, payers of all types – Medicare, Medicaid, GHC, private insurance – paid the claims. This is not to say that there might not be an insurance company that has AMA discharge as an exclusion in the benefit plan.
However, we have no evidence to support such a statement. Therefore, when a patient wants to leave AMA, make no speculative comments about insurance payment or non-payment in this context, just as you would never presume to know what insurance may or may not cover in any other clinical context.
For details on the steps to take when a patient wishes to leave AMA, please review UWHC Policy 4.19.
In summary, the important steps are:
- Inform the attending physician of the patient’s wishes.
- Confirm that the patient has the mental capacity to make an informed medical decision.
- Inform the patient of the medical risks of leaving.
- Document the medical risks that were explained to the patient.
- Attempt to have the patient read and sign the AMA form, if possible (although this is not essential).
Coordinated Care and clinical staff may wonder whether they should make arrangements for follow up appointments, home care, etc. for a patient who is leaving AMA. As the patient has been informed of the medical risks of leaving and has decided to accept those risks, we are not obligated to complete a safe discharge plan; that said, Coordinated Care and clinical staff may choose to assist the patient by making some follow up arrangements depending on the time available and the staff member’s judgment.
As always, feel free to contact Patient Relations, the Nursing Coordinator, or Risk Management for assistance.