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Tips for clinicians dealing with insurance company requests

Clinicians must take care when answering requests for patient information from insurance companies, Toronto health lawyer Kate Dewhirst tells AdvocateDaily.com.

Dewhirst, principal of Kate Dewhirst Health Law, says medical practitioners can be knocked out of their comfort zones when records requests come in regarding disability insurance, life insurance or other policies triggered by a health event, due to the huge impact coverage decisions can have on patients’ lives.  

“It’s a space where clinicians can feel like advocates, which is a different role than they are used to when providing care,” she says. “Front-line staff can also feel very uncomfortable about releasing certain information, even though it’s a thing they do routinely.”  

To help them negotiate those tricky waters, Dewhirst has prepared some key tips and answered some frequently asked questions based on her own discussions with health-care practitioners in primary-care facilities, family doctors’ offices, specialty care centres, hospitals and other work settings.  

Tip 1: Read the forms closely

When letters arrive from insurance companies, Dewhirst says staff at health-care offices should read them carefully to ensure the records they turn over precisely match the request. 

The accompanying consent form should also be studied for any red flags that suggest it may no longer be valid, Dewhirst adds.

“These forms can range from simple to complicated, but what you don’t want to do is to go beyond what is required. Sometimes it may seem easier to just copy an entire file and send it over, but you should only release what is specifically requested and consented to,” she says. 

Tip 2: Don’t intentionally mislead insurers

Dewhirst says its natural for medical practitioners to feel protective over their patients, given the personal nature of the information they hold about them.

“It can sometimes feel uncomfortable and invasive if you feel like they are asking for every waking thought the patient has ever had,” she says.

Despite that, she says health-care professionals should resist the temptation to edit their response to maximize the chance of coverage being granted.

“You have to be very cautious and make sure you are answering what is asked of you,” Dewhirst adds. “If you’re unsure of what to release, nothing precludes you from checking with the patient to ensure they understand the full extent of their consent.”

Tip 3: Don’t release without consent

In some cases, patients will object to the release of certain information requested by insurance companies. According to Dewhirst, medical professionals who are specifically asked for records that exist, but were vetoed by a patient, must acknowledge that they hold the information but that it has been withheld due to a lack of consent.  

“Unfortunately, the outcome may be that someone is denied coverage as a result,” she says. “There will be times when someone does not want to release information related to a particular incident because they are embarrassed, don’t feel it’s relevant, or for a variety of reasons. In these cases, clinicians should not mislead or omit information specifically required by insurers.

“Just because the outcome may be negative for the patient doesn’t mean you don’t have a responsibility to be truthful in your responses,” Dewhirst adds.

Tip 4: Beware the clinical summary

When confronted with an overbroad request, such as one covering many years of visits to a primary-care facility, Dewhirst says some practitioners offer to write up a clinical summary of their contact with a patient, with the idea of saving time and effort for both sides by filtering out irrelevant information.

However, she says clinicians who draw up such a summary also run the risk they will omit something more important.

“If it in any way deviates from the actual care provided, there are possible consequences for the clinician,” Dewhirst says, adding that if the omitted information reverses a coverage decision, the medical professional may become involved in disputes between insurance companies and the insured.

“A clinical summary can be appropriate, but you have to be diligent because it inserts the clinician into the system in a way they would not otherwise be included,” she adds.

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