Can insurer refuse to pay if I discharge myself from hospital?

[dineenp]

What is the name of your state (only U.S. law)? Pennsylvania

After a long wait, and fruitless attempts to communicate with nurses and doctors, a hospitalized friend waiting to be officially discharged told a nurse he thought he would just leave the hospital on his own. She told him if he did that his insurance would not pay. Is this true? What are a patient's rights and when does exercising them jeopardize one's insurance coverage?

[ecmst12]

It's possible. She would have to call her insurance company and ask them. But they don't want to encourage people to go against medical advice and possibly hurt themselves worse, leading to another admission with even higher costs.

[lkc15507]

I realize the post is a few days old, but I want to address it in case others read this with the same question in mind. ecmst12's answer is 100% spot-on. But, I want to kick it up a notch primarily because of the patient's rights question and the fact that I am a healthcare provider active in the payer industry.

A healthcare consumer is ALWAYS, but ALWAYS, free to refuse or accept healthcare. (I will except mandatory, court-ordered mental health detentions, which are subject to state laws.) That is one of 5 patient "rights". However, contrary to popular belief, rights concerning healthcare and healthcare reimbursement are NOT the same animal. Healthcare reimbursement by an insurer is a contractual issue, which will always be deliniated by a published policy made available to the consumer (should be at least, and if it's not made available, that is a separate issue). I'm not pretending to be naive in that remuneration factors can not or will not influence provider / patient decisions, but the fact is the patient may choose whatever healthcare he/she deems appropriate by accepting the financial responsibility. In fact, with our without insurance reimbursement, that is what a consumer does each time they seek healthcare. Trouble usually ensues when a consumer assumes that healthcare rights equals reimbursement rights.

I reiterate that ecmst is absolutly correct with the answer that "possible" is the correct answer given the payer denying the healthcare claims in the specific situation you posted. There are not enough specifics about the care or the plan to determine anything but "possible" that the claims could be denied. Yet, as I like to be brass-tacks and educate, I would substitue "quite likely" for "possible" based upon my experience and knowledge.

Most plans I am or have been familiar with will have a specific exclusion with regard to services presented to a payer when the patient leaves AMA (against medical advice). Even if a plan does not have that specific exclusion, I believe it would rely upon "medical necessity" provisions. Those provisions would include a subset of provisions such as being ordered by a physician, following reasonable stantards of care etc. The fact that a patient presents oneself to an ED does not necessarily establish medical necessity of any services renedered, including the ED charge itself. It would be subsequent healthcare action by the provider that would establish the medical necessity of the ED visit. If one leaves prior to receiving advice, it would be very hard to establish medical necessity for any part of the the visit. But, let's suppose the disgusted patient goes to another ED after leaving the first and does receive medically necessary care. A health plan would likely view the first voluntarily abandoned visit as just that--voluntarily abandoned--ie an unnecessary duplication of services which is exactly what ecmst12 refers to--higher, unnecessarily incurred (ie not medically necessary) charges.

[ecmst12]

Actually what I was referring to is if the patient leaves the hospital AMA before they are well enough to do so, then relapse shortly thereafter, and have to be brought BACK to the hospital, racking up many more charges then if they would have just stayed there until they were well enough to be discharged in the first place. But your situation applies too

[lkc15507]

Oops, sorry, didn't mean to put words in your mouth. I was interpreting that unnecessary / increased charges are just that, regardless of specifics. My bad, but I think we were somewhere on the same page. I do get passionate about educating between actual healthcare and healthcare reimbursement. I work with this every day and think that education is the answer. I take every available opportunity to do that, I don't and won't apologize for it either! As evidenced by my capitalizing on a days old post! lkc15507

[cbg]

(lifts hat to lkc5507) Well said, and I agree completely. (applauds loudly)

[lkc15507]

Thank you for the feedback, cbg. Coming from you that is truly a compliment. lkc15507