Why do insurance companies refuse to pay hospital bills if the patient signs himself out against medical advice? What happens if instead of signing out AMA the patient just refuses any further treatment (or to even allow staff to take vitals) and bascially just sits in her room waiting to be discharged?
Who says they won’t pay for the treatment received? I signed my kid out of a hospital AMA and we had no such problem.
I have never heard of such a thing and I work in an allied industry. I suppose if you refused treatments and the consequences were a much worsened condition, some insurance company somewhere might give you a hard time. However, group plans at least simply don’t work that way. There are legitimate reasons someone my refuse treatment from a doctor (to get a 2nd opinion perhaps). Group insurance agencies don’t even have the data to make that kind of decision.
I was in hospital last week. After two days I was cleared to go home by the surgeon (at 11am), but not my attending physician. He had ER duty that night and went straight to the ER when he arrived at 8pm. Apparently he wanted to wait until morning rounds to discharge me because he was busy and didn’t have time to come upstairs (neither of which I doubt). I had to threaten to sign out AMA several times until the nurses ran my chart down to the ER for him to look at (he hadn’t even seen in until then). The whole time the nurses kept telling me that if I signed out AMA my insurance (which I don’t have) wouldn’t pay.
Nursing staff aren’t billers or coders, and most of them don’t understand how the process works.
In order to be reimbursed for services rendered, hospitals and physicians have to bill on standard claim forms using standard codes. On the hospital claim form, there is a block for discharge status. (It’s here, if you’re interested. PDF file.) One of the items listed is “left against advice or discontinued care.”
However, insurance companies pay for covered services provided. There may be a provision in the contract which limits reimbursement for conditions that arise from complications due to the discontinuation of care, but since the surgeon discharged you at 11 a.m. and your primary-care physician didn’t discharge you for over 9 hours to the point where you had to threaten to sign out AMA, I’d say that probably wouldn’t be the case. However, it sounds like there would be sufficient grounds to appeal an insurance denial based on signing out AMA. YMMV.
Robin
My WAG is that the nurses were lying.
Most nurses I’ve known were kind, professional, competent, all the good stuff. But I’ve encountered a few in my many hospitalizations who were shall we say not stellar examples of the profession. And I’ve been lied to by at least one nurse. (That wasn’t the only unprofessional thing she did, and I reported her to the hospital administration at my earliest opportunity.) Just like everybody else, half of all nurses are below average.
The Great Doctor says “Don’t let him leave until morning,” and the unfortunate, overworked, browbeaten nurses say or do whatever they have to in order to follow “doctor’s orders.”
I’m not sure I’d characterize the nurse’s actions as malevolent. There was a procedure that needed to be followed and she was going to follow it, no matter what she had to tell the patient. It’s more resourcefulness than anything else, just not in a good way.
However, if I were alphaboi, I’d refuse to pay the portion of the bill that covered the period between the surgeon’s discharging him and the time his primary physician signed off. It sounds like there would be sufficient documentation to bolster such a claim; there wouldn’t be a note from the primary explaining why alphaboi shouldn’t be discharged, and the discharge was contingent solely on the convenience of the physician, not on any real medical necessity.
Robin
It actually is a common, if completely mistaken, belief among many hospital nurses that if someone leaves AMA than their insurance will refuse to pay. Better hospitals are aware of this and train against it, but it does still slip in. At one hospital I worked at, the hospital specifically forbade nurses to say that, made it policy that they could not say that, and instituted disciplinary measures for anyone who did say that. (And there were a few who still believed it. Go figure.)
It’s a widely held belief. No telling why, but it is.
I’ve never told a person that their insurance ‘may not pay’ because I don’t know that to be a fact. Insurance is a pretty clear contract and my experience is that insurance pays solely based on whather the service is a covered benefit at the time the service was provided. I have heard that idea that insurance ‘may not pay’ bandied about quite a bit though.
alphaboi867’s problem was that he was discharged from the consulting surgeons service but not from his primary admitting doctor. A consultant cannot give a ‘discharge home’ to a patient. Only the admitting (or whoever is covering for the admitting doctor that day) can write a discharge home order.
Also, if the admitting (or primary) doctor is off that day, the covering doctor is usually given instructions regarding the care and plan of the patient when the one doctor reports off to the other.
Since billing is done on a per-bed-per-day basis, it doesn’t matter to his bill if he were discharged at 7 am or 11 pm.
But there should be a plan in place to notify the admitting physician or his covering doctor when a patient has been discharged from the consultant’s care. The patient shouldn’t have to cool his heels in a hospital room for several hours because no one thought to call someone at his primary’s office to arrange a discharge visit.
But that didn’t happen here. He was kept waiting until the original admitting doctor came to the hospital to work his regular ER shift. From the OP, it does not seem like anyone made an effort to get in touch with him or anyone else to arrange for discharge. I could be wrong; for all anyone knows, the nursing staff tried to call his office and was told that alphaboi would have to be discharged by the admitting doc, but based on the rest of the information, I doubt that
No, but I think a discount may be in order, along with a review of the applicable policy/procedure and a talking-to for the nursing staff about inappropriate assertions made to patients.
Robin
A nurse tried this on me once. I pulled out my cellphone, called my insurance company, asked the rep. on the phone about the company’s payment policy for AMA, was assured that while the insurer did not suggest checking out AMA it had no bearing on payment. I informed the nurse of this and suggested that if she wanted me to sign out instead of just leaving, she have the necessary form and a pen in my hand by the time I made it to the hospital exit.