Frequently Asked Questions

What are my responsibilities if a third-party payer does not approve care I recommended?

Answer

Insurance coverage does not dictate clinical needs or decisions. Physicians must advocate for the care or treatment warranted by a patient’s condition. Physicians should be aware of the appeal and grievance processes and if necessary, make an appeal or facilitate an appeal by the patient or employer. Based on the outcome of the advocacy efforts, the physician should obtain the patient’s consent for treatment, or refusal of treatment. The patient should be made aware that in instances in which the insurer refuses to grant payment, the physician is not refusing to do the procedure/treatment. However, an alternative method of payment will need to be agreed upon. If appropriate, the physician may want to discuss reasonable alternatives to a rejected treatment plan with the patient and his/her family members. The physician also may want to assist the patient with alternative payment options. Most importantly, all discussions, appeals and decisions should be carefully and thoroughly documented in the patient’s medical record.

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