This husband chronicles the high cost of chest pain
His wife went to the ER for chest pain. She ruled out and had an inpatient stress test. The insurance company denied the claim:

“Just three days later, we received a letter from Empire thanking us for our “medical service authorization request.” It was denied. The stated reason: “Not medically necessary.” The letter, signed by a doctor, elaborated that “using evidence-based criteria,” the company was “unable to approve the requested coverage for acute inpatient hospital stay for evaluation of chest pain.” The letter continued:

“Information received indicates stable vital signs, negative cardiac enzymes and that that patient was discharged to home the next day after a negative stress test. There is no indication of abnormal EKG, previous history of unstable angina or heart attack. As such, the evaluation of this patient, including stress test, could have occurred in a setting other than acute inpatient.”

As defensive medicine becomes more frequent, cases like this will become the norm. What happened here (i.e. stressing the patient prior to discharge) is not uncommon. If the patient had a heart attack while waiting for the outpatient stress testing, the physician would have been sued for not doing it sooner. Pick your poison.

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  • the patient’s advocate

    What state is this? If it has a prudent layperson standard for ER, then the whole issue becomes somewhat fuzzier. Why was this patient admitted?
    It was the hospital’s call – not the patient’s to be admitted. Looks to me like the hospital should eat this one.

    Lin

  • DrTony

    It is never “the hospital’s call” for a patient to be admitted. Not to seem like an a**hole, but the hospital is just a building. I mean, some person, not a building, made the decision that the admission and testing would occur.

    You might argue who this decision rested with. Was it the ER doc, the admitting MD or the patient?

    In my view, it is always the patient. They may have an argument with the insurance company that the admission was necessary given the advice they received in the ER or doc’s office, but it was the patient’s decision.

    I frequently advise patients in the ER about admission. I tell them what my recommendations are but make it clear that the decisions rest with them.

    It is unreasonable that the doctors should accept financial liability for recommending care for which an insurance company later denies payment.

    I feel strongly that the patient’s relationship with his insurance company is just that: his relationship, not mine.

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