What
the statutes mean
An insurance company is not allowed to
interfere in the relationship between a doctor and his or her patient. The insurer
is not allowed to substitute their opinion for the clinical judgement of the doctor.
Some
doctors have tried to argue that the “medical necessity” or pre-authorization
requirements of an insurer interfere with the doctor patient relationship. While
it may appear to do so, that is not the case. It is not the insurer that owes
the chiropractor for his or her services. The patient is always responsible for
the payment of services unless the chiropractor has given up this right by signing
a managed care contract.
Billing an insurance company is done as a courtesy
for the patient. Because doctors and their staffs do not always take the time
to explain that insurers place artificial restrictions on chiropractic care, patients
assume that the insurer will pay for any service provided by their chiropractor.
When the insurance company states that some care was not “medically necessary”
the patient incorrectly assumes the chiropractor did something wrong.
Interference
would occur if an insurer tried to dictate the treatment plan of the chiropractor.
“Medical necessity” decisions are not interference because insurers
do not forbid the doctor from providing care. They refuse to pay because the care
does not qualify for reimbursement under the terms of their policy. Much of this
irritation can be eliminated if doctors and their staffs explain the payment responsibility
to each patient and reinforce the fact that there is not an unlimited benefit
for chiropractic care.
Statute excerpts628.37 Preservation of
professional relationships in professional services. No insurance plan related
to or providing health care, legal or other professional services may alter the
direct relationship and responsibility of professional persons to their patients
or clients for the professional services rendered. All professional relationships
are subject to the same rules of contract and tort law and professional ethics
as if no insurance plan were involved.
