What do you do when managed care won’t pay for a test?
Even in managed care, the surgeon bears responsibility for any delay in obtaining approval for recommended tests. A surgeon who wants a test done but anticipates a roadblock from a managed-care company can’t say, weeks later, “The insurance carrier didn’t approve it.”
You may not have much input, but blaming the system is a poor legal argument. You may have to ask the patient to do more to obtain approval or offer the patient the option to pay for the test out of pocket.
If managed care refuses initially or repeatedly to pay for important tests or procedures, you must document that you or your staff explained the situation to the patient and extended the patient an opportunity to pay for the test without reimbursement.
Plaintiff patients in this situation typically say, “Of course I would have paid X dollars for that CT scan.” Such assertions ring true with jurors. Patients will never say, “I support the doctor who never told me about something because he thought my insurance wouldn’t cover it.”
In court, you can’t blame managed care or remove an option simply because you personally thought some entity ought to pay for it.
Intraoperative concerns
Most claims against surgeons focus on what happens in the operating room or immediately postoperatively. The Physician Insurance Association of America recommends several strategies to reduce or avoid operating room claims6:
- Obtain adequate training and supervision when using new surgical equipment
- Ensure that the patient gives informed consent for a procedure and that you have provided adequate information regarding risks and alternatives
- When working as an attending physician with residents or internists, make sure they are under proper supervision
- Participate in any hospital-sponsored risk-management program.
Postoperative concerns
Your liability continues after surgery. In the hospital, you must communicate clearly with nurses. Use the chart as a tool to enhance patient safety. Document your observations thoroughly.
If you bring in consultant physicians to deal with a preexisting problem or one that arose after surgery, be aware that all clinicians involved must communicate. “I never talked with my consultants. We communicated through progress notes,” will not help a defendant-physician’s case. Such notes, which tend to be terse and hard to read, should never serve as the main method of communication.
A surgeon must communicate fully with the patient, and with the family as well. At least a dozen reports have established that patients, or their family, filed a lawsuit simply because they felt that was the only way to find out what happened.7,8
The author has no affiliations to disclose.