Consent key for insurance information requests: Sunshine

By Staff

Clinicians should seek legal advice when in doubt about information requests from insurance companies concerning their patients, says Toronto health lawyer  Elyse Sunshine.

Sunshine, partner with  Rosen Sunshine LLP, tells there are a number of contexts in which insurers might contact health-care professions of various stripes for information about their patients or their patients’ files, including:

  • medical assessments as part of a claim by the insured patient
  • audit of insured patient’s past claims for accuracy
  • audit of health provider’s past treatments

When the health professional or the clinic itself is the subject of an insurer-led audit, Sunshine says there may be a way to turn over the necessary documentation while anonymizing individual patient details.

Insurers may ask for documents with patient names blocked out, depending on what they’re looking into,” she says. “But health professionals should seek advice as to whether they have the authority to release that information, whether it contains identifying information or not, as they may need patient consent depending on the specific situation.”

In general, Sunshine says patient consent is key to any request.

“Just because the insurance company has a relationship with your patient doesn’t mean they are entitled to the patient's personal health information,” she says. “You have to treat the request as if it came from any other third party — even their own lawyer — and make sure the patient consents to the release of information.”

In cases where patients object to the release of certain information requested by insurance companies, Sunshine says medical professionals may have to explain to them the ramifications of refusal since health-care providers are unable to deny the existence of records they hold.

“It’s ultimately up to the patient to decide whether something gets released, but if they refuse, it could potentially interfere with the coverage or benefits they are seeking or receiving,” she says.

“Clinicians can outline the risks and benefits of the decision so that the patient has a full understanding of what they are doing,” Sunshine says.

Whatever information is ultimately turned over should only leave the office in a copied and secure form, she adds.

“The originals should be retained by the holder of the record unless there has been an order of a court or other body specifically directing the release of originals,” Sunshine says.

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