Physician vs. Insurer: What to do When Insurance Takes Over Patient Treatment

(Digested from Medical Economics, January 5, 2007)

Utilizing a three-drug regimen, you have been able to stabilize and control a patient's blood pressure as part of a treatment protocol for a small hemorrhagic CVA. One of the three medications is at doses higher than the recommended level. After 18 months the patient calls to say, "My insurance company will no longer cover the drug that is being used beyond recommended levels. They said that you have to prescribe something else or lower the dose." What should you do?

First, remember that the insurance company does not have a license to practice medicine and you are responsible for any action that you take. If the medication is revised and the patient deteriorates, you – not the insurance company – will be the target of a lawsuit.

Insurance companies, by law and contract, can make coverage decisions. They can decide what they will pay for – or not pay for. If there's more than one treatment possible, they can choose the least expensive, provided that it's not contraindicated nor proven to be ineffective. They can't dictate which treatment you should use – that's a therapeutic decision for which it may be liable.

In the above case, the insurer approved the medication, not the dosage. The company was making a clinical judgment to demand a lower dose, not a determination of medication. As such, the insurer made a therapeutic decision.

If the insurance company won't acknowledge that, you need to make a decision to tell the patient to stick with the recommended therapy and perhaps provide pharmaceutical samples or refer the patient to a medication assistance program.

Make sure that you document your decision and your actions. Notate it in the chart and send a letter to the patient specifying your medical advice and actions taken to persuade the insurer to re-evaluate their decision. Also send a certified letter to the insurance company indicating your concerns and possible consequences of their actions. You're your belief that they are making a "therapeutic" decision and why. Copy your