Financial responsibility of hospitalized patients who left against medical advice: medical urban legend?

Abstract

Background: Physicians may counsel patients who leave against medical advice (AMA) that insurance will not pay for their care. However, it is unclear whether insurers deny payment for hospitalization in these cases.

Objective: To review whether insurers denied payment for patients discharged AMA and assess physician beliefs and counseling practices when patients leave AMA.

Design: Retrospective cohort of medical inpatients from 2001 to 2010; cross-sectional survey of physician beliefs and counseling practices for AMA patients in 2010.

Participants: Patients who left AMA from 2001 to 2010, internal medicine residents and attendings at a single academic institution, and a convenience sample of residents from 13 Illinois hospitals in June 2010.

Main measures: Percent of AMA patients for which insurance denied payment, percent of physicians who agreed insurance denies payment for patients who leave AMA and who counsel patients leaving AMA they are financially responsible.

Key results: Of 46,319 patients admitted from 2001 to 2010, 526 (1.1%) patients left AMA. Among insured patients, payment was refused in 4.1% of cases. Reasons for refusal were largely administrative (wrong name, etc.). No cases of payment refusal were because patient left AMA. Nevertheless, most residents (68.6%) and nearly half of attendings (43.9%) believed insurance denies payment when a patient leaves AMA. Attendings who believed that insurance denied payment were more likely to report informing AMA patients they may be held financially responsible (mean 4.2 vs. 1.7 on a Likert 1-5 scale, in which 5 is "always" inform, p < 0.001). This relationship was not observed among residents. The most common reason for counseling patients was "so they will reconsider staying in the hospital" (84.8% residents, 66.7% attendings, p = 0.008)

Conclusions: Contrary to popular belief, we found no evidence that insurance denied payment for patients leaving AMA. Residency programs and hospitals should ensure that patients are not misinformed.

Figure 1.

Percentage of Physicians Who Believe Patients are Held Financially Responsible When They Leave AMA (difference between attending and resident responses analyzed using Wilcoxon Rank Sum test, showing residents agreed more strongly that patients are held financially responsible, p < 0.004).

Figure 2.

How Physicians Learned that Patients Leaving AMA May be Financially Responsible (physicians were instructed to check all response options that applied). *p = 0.006 by Fisher’s Exact test showing that among residents, other residents were more likely source of information regarding insurance denying payment for AMA patients compared to attendings. Fewer responses were noted for nurse, hospital administrator, medical school, hospital staff, and other.