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Does insurance pay when you leave the hospital against medical advice?

stamp approved and not approved with red text isolated on whiteThe more I read about women birthing in hospitals, the more stories I read of women who are lied to and threatened.  If we can’t trust our provider, how can we trust when they say we need a cesarean?

Don’t get me wrong, there are great hospital-based providers out there, but it can be really hard for your everyday mom to be able to connect with them. Generally, care providers can be broken down into three categories.  There may be a supportive provider in your area, you just need to know where to look.

Here is an email from a home birth midwife, shared with permission.  In this case, parents were told that if they didn’t comply with the doctors recommendations, and left the hospital against medical advice, their insurance would not pay:

Short version: had a postpartum transport last night and since baby was born OOH [out of hospital] and was a nice healthy 9#, parents had a difference of opinion with the hospital staff about how much input, if any, the hospital would have in baby’s care.

Deciding that staying would be one long argument after another, the parents decided to sign out AMA if the hospital wouldn’t budge on what they wanted to do.

The thing that almost made the parents cave was the OB’s comment that if they left AMA [against medical advice] the insurance could (actually would) refuse to pay for care mom had received.

My understanding is that insurance will pay for the care rendered, but if a patient signs out AMA, the insurance can decline/refuse to pay for subsequent care needed.

Comments or suggestions of where to find this answer.

BTW: a very kind nurse stepped into the situation and convinced the nurse supervisor to compromise.

When I looked into this, I found this 2010 article from Emergency Physician’s Monthly which stated, “Fifty seven percent of all health care providers (and probably just as many patients) believe that if you leave the hospital or the emergency department against medical advice, insurance companies will not pay for the visit. Half of doctors surveyed have told or would tell patients that insurance would not pay the bill if they left AMA.”

Yet, a 2010 study examined how 104 AMA insurance claims were processed by 19 insurance companies and found that each and every one of them was paid.  They concluded, “Our study suggests that insurance companies not paying for ED [emergency department] visits of patients leaving against medical advice is a myth. ” (Wigder, 2010)

This article from the American Medical News cites another 2014 study reviewing the claims of 526 people who left AMA. The only claims that were not paid were due to administrative errors. “Not a single claim was turned down for insurance payment because the patient self-discharged.”

Why does this happen? American Medical News suggests, “People who investigated the issue suspect the myth emerged out of a desire to persuade patients to do what physicians believed was best. Eighty-five percent of residents and 67% of attendings said they told patients this information ‘so they will reconsider staying in the hospital.'”

So while it can be quite persuasive to hear that your insurance will not pay if you leave AMA, it’s simply not true.

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5 comments to Does insurance pay when you leave the hospital against medical advice?

  • Cynthia

    When I was pregnant with my daughter in 04 I was 1 week overdue and at that visit was already 3 cms so I was ‘forced’ to go to L & D for a BPP and then to be induced since “no one wants you walking around with a partially dilated cervix”. After a good cry and pep talk with my doulas I refused the induction and had to sign AMA forms for that…the main OB on the floor came in and said I HAD to come in that friday ( 41w6d) to be induced or my insurance would/could refuse to pay for the birth later…ESP if anything went wrong ( she started citing statistics on stillbirths going up after 42 weeks and such). Not fun. Totally untrue of course, but I didn’t appreciate the stress.

  • Does anyone know if postponing a surgery AMA will affect insurance coverage?

  • Beckie: I think it is technically true that an insurance could refuse to cover a surgery if you go AMA, though I haven’t heard of this actually happening. What I have seen is insurances refusing to cover a hospital stay, especially at an out-of-network hospital, if you sign out AMA. They use the argument of “medical necessity” to get out of paying. If you refuse a surgery, then it must not be medically necessary. This wouldn’t apply if you were getting a second opinion or looking into other options, and would require your doctor documenting well the reasons for your refusal, so you need him/her on your side.

  • Doula

    Hi, I have been looking into this issue because of a situation with someone I know where the insurance company did tell her they would not pay for the birth if she refused an induction AMA. Perhaps if she had fought hard, she could have reversed them. But it’s important to note that theoretical rights don’t always translate to reality – it’s hard enough arguing with a doctor or nurse while on your back strapped to monitors, imagine having to fight with the insurance company too.

    • Jen Kamel

      Thank you for your comment! I’d like to better understand what happened with your friend.

      So your friend was told that she needed an induction and if she didn’t have the induction, she would be charged for… what?

      Did your friend ultimately have the induction?

      Or did she check out AMA and then was charged for something? What exactly was she charged for?

      Best,

      Jen

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