How is it legal for insurance to deny payment if you leave hospital AMA?

[MegBoz]

"If you sign out of the hospital AMA, insurance can and will deny payment for the entire stay."
I've seen this posted on MDC before & it absolutely, positively baffles me.

The whole idea of "Against Medical Advice" leading to non-payment from insurance... it baffles me. How is it legal?

OK, if you try to FORCE your HCPs to DO something (give a drug or administer a procedure) that is AMA, then I can see where insurance would deny payment. Let's say you don't have cancer, but you try to get them to give you chemotherapy. It totally makes sense for insurance to say, "The docs say you shouldn't have had that procedure, but you tried to force it through anyway AMA so we're not paying."

That seems logical to me. I get that.

But when the doc wants you in the hospital for 48 hours after giving birth & you want to just go home at 36, you are trying to DECLINE CARE - you are DECLINING a recommended 'procedure' .(Hospitalization being the procedure in this case.)

So, to rephrase:
If you don't follow docs orders & submit to the procedure that's recommended, insurance won't pay.

That is honestly, exactly, and precisely what it equals.

So in that case, why don't they also say, "If you don't submit to a CS, we won't pay for your vaginal delivery." or "If you check into the hospy for birth, and want to go home when labor slows (But the docs want to start pit or do CS,) we won't pay for that stay." Those seem to me to be the same thing.

I don't get it. How on earth can it be legal for them to deny payment for services rendered simply because you don't consent to everything the doc recommends?

[stik]

I am pretty skeptical about this too. There is no billing code for "patient left AMA." If anything, you leaving the hospital AMA is cheaper for the insurance company. They have no financial incentive to discourage you from walking out, and we know that insurance companies aren't motivated by concern for your health.

I think this is one of those things that hospital workers sometimes say to encourage a patient to stay, but I don't think it's actually true. I've heard of nurses saying it, but nurses aren't typically involved in billing. I don't think it is legal for insurance companies to deny payment for covered services because a patient declines other covered services, even if those services are recommended. My health insurance company pays for my dd's well-baby visits and asthma medication even though I vax on a delayed schedule, for example, and they will continue to pay for my kids' well visits even though I have missed a few visits in the recommended schedule due to being a flake. And if it was legal for them to not cover these things, honestly, I think they wouldn't.

[texmati]

i think what they mean is if you leave ama, and then something happens (baby get sick, ect) as a cause of you leaving ama, the insurance would have a reason not to pya.

[cileag]

Yes, what Texmati said, the only times I've seen it be a problem was in the case of leaving early and then readmittance later on for something like jaundice when maybe you left prior to performing a transcutaneous bilirubin check. The other issue I see often is that in the hospital I work in is that the Homehealth visit is not covered unless you leave prior to 48 hours after the birth for a vaginal birth or 782 hours for a c/s.

[MegBoz]

Originally Posted by texmati

i think what they mean is if you leave ama, and then something happens (baby get sick, ect) as a cause of you leaving ama, the insurance would have a reason not to pya.

Ah! That makes a lot more sense.

Still, though, the same could be said for any other 'procedure.' "You didn't consent to CS (for breech, ERCS, FTP, whatever) & so we won't pay for care to the baby if baby has problems upon birth." (Cuz maybe those problems could have been presented if you had consented to CS.)

It's difficult to prove that one action caused a medical problem to arise. Babies & Mothers who are checked out of the hospital WITH medical approval still need to come back for problems sometimes afterward.

It still seems like a really slippery slope to me.

[lunarlady]

When you leave AMA, the doctors have to file WHY it was AMA. Meaning AMA because they are worried about xyz happening, or see xyz signs that pdq will happen in the near future.

If you leave AMA, for example maybe they want to observe you after birth, but you and baby are totally fine and decide to go anyway. They might record that standard observation time is x, you left after time y, but showed no signs of problems. When you sign out AMA, you can look to see the reason they put. This is important if you are going to do it, because you can be liable for the bill in certian instances.

What insurance is looking for is something like this: You birth, then are running a 101 degree fever. Baby is lathargic and not eating, and is also running a fever. Staff wants to treat with antibiotics. You refuse and leave AMA. Two days later you and baby are admitted with systemic infections and need serious round the clock care for several weeks. In this senerio, insurance can justify denying payment for the second round of care as they are reasonable to assume that you should have had a cheeper, less extensive treatment in the first place, and it's your fault that you got so sick.

But you have to realize that this type of senerio is very, very rare. You are not actually leaving AMA if you can find ONE doctor who agrees that you are good to leave, and have that doc sign your discharge order. Unless you really should be under medical care, you can usually find that one doc. Even the normal doctors can be pursuaded to sign your discharge if they feel you will leave AMA otherwise. They don't want to battle the insurance company any more than you do.

[CherryBomb]

What lunarlady said.

[mwherbs]

although many providers and nurses believe this it isn't true here an article and I found a couple others but this is good

http://www.annemergmed.com/article/S...798-3/fulltext