Tuesday, March 01, 2005

Abdication of Professional Duty?

The Special Report of the February 7, 2005 issue of Modern Healthcare discussed “External Review” programs - legislated mechanisms by which subscribers can appeal decisions by health insurance companies to refuse payment for services that they determine to be unnecessary or otherwise not covered by their health insurance policies.

Two things about the article caught my attention.

The first was the casual way in which denial of payment was treated as denial of service. Perhaps some will consider that to be hair-splitting. But I think the distinction is important for reasons that bring up the second thing, which was the nearly total lack of any reference to the role of providers in these disputes.

It seems to me that a health care provider who decides that a patient needs a particular service has a professional obligation to make sure that the patient gets it. On that basis, denial of payment by the insurance company on the grounds that the service was unnecessary not only creates a financial issue in which the provider ought to be active on the patient’s behalf, but also, in effect, accuses the provider of incompetence – not something to be taken lightly.

On the other hand, if such a denial is upheld by competent reviewers, then the provider ought to wonder if a mistake was made that calls for corrective action.

Apparently the provider community doesn’t see it that way. The article reported that providers were often reluctant to furnish the medical records needed by the patient for an appeal, considering it “just another administrative hassle.”

That sounds like an abdication of professional duty to me.

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