Chronically painful
Moderator Emeritus
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15+ Year Member
Nov 27, 2002
Las Vegas, NV
Attending Physician
When a patient leaves AMA they are often denied coverage for the visit by their insurance companies. I never ran into this in residency (or I was never aware of it) but it has become a big problem in private practice. We all se patients who come in, get a work up, but then don't want to be admitted. I can understand that and to be honest I like the patients who don't want to be in the hospital better than the ones who would live there if they could. The problem is that I am seeing patients who don't want to stay and don't want to sign AMA because they don't want to bear financial responsibility. Sometimes I just document that they were offered admission and refused but I don't make them sign AMA. This fixes their financial problem but it puts me at risk. This all or nothing scheme by the insurance companies reminds me of the time when if someone wanted to AMA they were unhooked and thrown out of the ER with nothing. Now we treat up to the limits placed by the patient. Eg. A chest pain that wants to AMA goes with ASA, NTG and is told that they can come back at any time. It's unethical to slam the door on a patient just because they won't agree to everything. This insurance policy is just as unethical.


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15+ Year Member
Feb 24, 2003
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I run into this a fair amount as well and I always dictate in my note a detailed explanation of what I discussed with the patient, who else was present (family, nurses name, etc...) and that I offered them admission, further workup, treatment, etc... but that they declined and left the hospital without signing the AMA form. I figure since I have been told that the AMA form doesn't really guarantee you that much protection anyway and that it is what you document at the time of the encounter that will make or break you that this is probably as good as I can do.

I have to agree I don't really understand the insurance companies stance on this since it seems to me by leaving AMA the patient is saving them money. If he lives they've avoided the cost of admission and workup, If he dies that saves the insurance company even more, If he becomes permanently disabled they probably don't pay for long term care anyway.


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15+ Year Member
Feb 1, 2004
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Yes, I agree that the whole AMA and patient liability thing is very unethical. From an insurance co's perspective, I think that they require patients to pay out of pocket because besides the benefit to them of not having to pay for the hospital visit, their thought is that whatever treatment the hospital may have started may end up being wasted, and if the patient survives to return to the hospital, his or her care may be more expensive then it would have been had he or she decided to stay as directed during the first time. It does present a serious problem to physicians who are trying to be "reasonable" with the patient though, I had patient with classic worsening angina and known coronary artery disease in the ER, but he was out of state and had an appointment with cardiologist the next morning. My EM attending ended up discharging him instead of forcing him to sign out AMA like he wanted to, and dictated in his note that the patient was advised that he was high risk but that the patient wanted to return home to see his own cardiologist. The scary part is that had the patient died after being discharged, I'm pretty sure that the family could have come back and sued the ER physician for discharging them even though it's what they were insisting upon. Jurors don't buy the arguement that physicians were just doing what the patient wanted, my understanding is that lawyers can make pretty good arguements how the physician should have known better and ignored the patient's wishes or allowed them to sign out AMA if they really wanted to. It's a tough line between being compassionate towards your patient's pocket book while protecting yourself against malpractice lawyers.
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