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Who's at fault, the doctor or the insurance company?

Jan. 3, 2007

Question:
My doctor refused to take X-rays of my hip after a fall and now there is permanent damage. He had told me that the insurance company would not pay for them. Who's at fault? The doctor or the insurance company?

Debbie, Michigan

Answer:
Dear Debbie,

The answer to this question involves asking yourself more questions in the vein of "Which came first, the chicken or the egg?"

  • Is your hip damage from the fall, or from your doctor's failure to diagnose and treat?
  • Would your age and existing health condition (in addition to the nature of your fall) have prompted other physicians to order the X-rays in keeping with routine standards of care?
  • Would the result of the X-rays have affected the treatment decision?
  • Did your doctor order the X-rays and the insurer turn him down? Or did he fail to order the X-rays at all?
  • Were you given the chance to pay for the X-rays yourself? If so, did you decline?

Although it doesn't seem likely your insurer would deny the X-rays if your doctor insisted they were medically necessary, I am going to assume that your doctor sought precertification from your health insurer and was turned down. Your doctor is still on the hook unless he/she can explain why the X-rays were not medically necessary and would not have been ordered by another physician with the same skill and training, according to Maria K. Todd, a national consultant and negotiator in managed care disputes. Todd points to Varol vs. Blue Cross & Blue Shield (BCBS) of Michigan, a court case where a group of physicians challenged a BCBS precertification requirement on the grounds that it affected their ability to diagnose and treat patients. The Michigan court rejected the doctor's argument, saying that physicians retain the right, as well as ethical and legal obligation, to provide appropriate care, whether or not the treatment is preapproved.

For more information on what to do when a claim is denied, read Claim denials: Who's responsible when your health plan doesn't play by the rules?

You may have grounds to sue your doctor if you, or your attorney, can prove that routine standards of care were not met in your case and your doctor did not inform you that you could pay for the X-rays yourself.

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