Insurers not paying when patients leave hospital against medical advice is a myth

Many physicians believe this to be true, but researchers say doctors shouldn’t use insurance to force compliance.

By — Posted July 5, 2012

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If you’re a physician telling patients that insurers won’t pay if they don’t follow doctors’ orders, a study says you should stop — because it’s not true.

An article in the July Journal of General Internal Medicine reported an analysis of data on 526 patients leaving against medical advice from University of Chicago hospitals from 2001 to 2010. Of the group, insurers denied 18 payment for hospital care, but this was primarily due to administrative errors such as misspelled names. Not a single claim was turned down for insurance payment because the patient self-discharged.

The authors also surveyed 51 residents and 41 attending physicians at the institution. Sixty-eight percent of residents and 44% of attending physicians said insurers would not pay for a hospital stay if a patient left against medical advice. Also, 71% of residents and 51% of attending physicians always or often told patients they may be held financially responsible for any bills related to the stay if they left against their counsel (link).

Research and anecdotal evidence suggest this nonpayment myth most likely goes beyond the University of Chicago. A survey of 114 residents from other institutions found 40% believed insurers would not pay if patients left against medical advice. When the data were presented as a poster at two medical meetings in 2011, numerous physicians reported to the authors that they believed this to be true.

People who investigated the issue suspect the myth emerged out of a desire to persuade patients to do what physicians believed was best. Eighty-five percent of residents and 67% of attendings said they told patients this information “so they will reconsider staying in the hospital.”

Insurance coverage rules can be byzantine, making them a fertile ground for rumors. And this one, in particular, may have been true for some insurance policies years ago. In 1990, the Arkansas Supreme Court ruled that the state’s BlueCross BlueShield organization could not deny payment for a hospital stay even though the patient left against medical advice.

Researchers said there was no evidence physicians were lying to patients about insurance coverage. However, they said doctors trying to ensure patients are compliant with their care should make their case with correct information.

“Our patients put their trust in us to give them accurate information,” said Gabrielle R. Schaefer, lead author and a fourth-year medical student at the University of Chicago’s Pritzker School of Medicine. “Misinformation should not be used to coerce patients to do something.”

The authors say the study indicates that the communication of how new pay models work may be very challenging. For example, several studies have found patients who leave against medical advice have a higher risk of worse outcomes. Within an accountable care organization or other payment model, this behavior may lead to penalties for the institution. This does not, however, mean the patient will be responsible for the bill.

“The landscape is changing so much,” said Vineet Arora, MD, one of the paper’s authors and assistant dean of scholarship and discovery at Pritzker. “There’s a potential for misinformation to be spread, and it’s hard to defuse a rumor because no one actually knows the truth.”

There is evidence that the no-payment myth pops up in emergency departments as well. A study in the April 2010 Annals of Emergency Medicine reviewing 104 patients who left a suburban Level I trauma center against medical advice found insurance paid for all services rendered. Researchers surveyed 70 medical students, residents, attending physicians and nurses, and 57% believed insurance would not pay for the care of these patients. Fifty percent of the health care professionals said they told patients this (link).

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