AMA: 2 high risk myths and misconceptions

AMA: 2 high risk myths and misconceptions

2016-11-11T19:18:19+00:00

ExitSignPatients who leave the emergency department against medical advice (AMA) are at an increased risk of having a bad medical outcome, and can be a source of significant medicolegal risk to providers. Earlier we reviewed eight elements to address when signing a patient out AMA. There are two common myths regarding patients who leave AMA that can complicate an already difficult situation.

 

1. If a patient leaves AMA their insurance will not pay for their visit.

This is a commonly stated misconception among both providers and patients. A recent survey found that over 50% of emergency providers believed that insurance companies will not pay for visits when the patient leaves AMA. Recent studies have shown that this misconception is more prevalent among resident physicians, and that this statement is most often used as a means of convincing the patient to stay in the hospital.

Despite the prevalence of this myth, there is essentially no evidence to support this concept that leaving AMA would place an extra financial burden on the patient. Wider et al. reviewed over 100 such ED cases. The patients were covered by 19 different insurance companies including Medicare, Medicaid, and workman’s compensation.The authors found that all of the cases were fully reimbursed by the insurers despite the patients leaving AMA [1]. Schaefer et al. examined 526 cases when the patient left AMA and found that while payment was refused in ~4% of these cases, there were no instances where payment was refused because the patient chose to leave AMA [2]. Providers should work to prevent patients from leaving AMA; however, there is no evidence to support using the threat of insurance non-payment to persuade patients to stay.

2. Patients must sign the AMA paperwork in order to leave the hospital.

Patients do not have to sign formal AMA paperwork when they decide to leave the hospital. In reality these forms, which are commonly forced on patients, offer minimal legal protection and in some instances may increase provider risk.  The general wording on most AMA forms states that by leaving against medical advice, the patient releases the hospital of any liability or malpractice claims. In several cases, courts have ruled that it is illegal for a hospital to require a patient to sign a waiver of liability as a “condition of their release”[3]. In a review of several similar cases, Devitt et.al concluded that the widespread use of AMA “waivers” offers little protection to providers. Most of the cases involving AMA paperwork have involved situations where the provider forced a patient to sign a form and then relied on this as a sole means of documentation.

Instead of focusing on having a patient sign a particular form, providers should take the time to chart a detailed account of their discussions with the patient. When signed, AMA paperwork may provide some supporting evidence that the patient and provider discussed the discharge, but it does not offer any significant legal protection [4]. AMA paperwork should be completed if patients are willing and cooperative, but is not mandatory when patients decide to leave against medical advice.

To limit adverse outcomes for both patients and providers, all attempts should be made to limit the number of patients who leave AMA. Rather than trying to intimidate patients into staying, or forcing patients to sign liability waivers, providers should focus on having a detailed and well-documented discussion with all patients who leave AMA.

  1. Wigder HN, Propp DA, Leslie K et-al. Insurance companies refusing payment for patients who leave the emergency department against medical advice is a myth. Ann Emerg Med. 2010;55 (4): 393. Pubmed citation
  2. Schaefer GR, Matus H, Schumann JH et-al. Financial responsibility of hospitalized patients who left against medical advice: medical urban legend? J Gen Intern Med. 2012;27 (7): 825-30.  Pubmed citation
  3. Dedely v Kings Highway Hospital Center, 617 NYS 2d 445 Supp, 1994.
  4. Devitt PJ, Devitt AC, Dewan M. An examination of whether discharging patients against medical advice protects physicians from malpractice charges. Psychiatr Serv. 2000;51 (7): 899-902.  Pubmed citation 

This post belong’s to Dr. Matthew DeLaney’s series on Everyday Risk in Emergency Medicine (EREM).                  

Matthew DeLaney, MD

Matthew DeLaney, MD

Assistant Professor of Emergency Medicine
Assistant Medical Director
University of Alabama at Birmingham
  • ER doc

    Although I realize that it is, I still don’t understand why leaving AMA is such a high risk medico-legal activity. If in 2 lines on the chart, you document the patient is capable of decision making, and the patient understands the risks/benefits of leaving versus staying, that should be all that is required. This still is a free country and you can’t force a patient to stay in the hospital except under very limited circumstances, such as AMS or SI among other conditions. For a patient to leave against your advice, and then later claim you are somehow at fault for not keeping them against their will, is quite frankly someone looking for financial compensation for their own poor decisions.

  • Joe Lex

    Agree with ER doc – we are advisers to the patient in a shared-decision-making process. Forcing someone to be hospitalized against their will is called “kidnapping.” I struggle to explain these concepts to many of my residents, who are still in a paternalistic “do as I say” mode.

  • Ric Solís

    One more myth, at least locally, and specially amongst our nurses, is that the AMA Patient cannot/should not be provided with discharge instructions/prescriptions. I’m not sure where this belief came from, but it is a practice that definitely increases poor outcomes and liability. Patients that leave AMA (and are cooperative with the discharge process) should receive appropriate prescriptions, discharge instructions that include a documentation of the risks of leaving before completing workup and treatment and appropriate follow-up instructions.

    • Matthew DeLaney

      Ric,
      I totally agree. The goal is to minimize bad outcomes for the patients, so anything you can do in terms of Rxs, followup, instructions to improve their outcomes will only help you in the long run.

    • Lakshay Chanana

      I have also seen this practice of not providing discharge summary/prescriptions to those who are leaving AMA. I was also taught this as a resident but I think It is unfair and they must receive these docs and proper instructions like any other discharge.

  • Matthew DeLaney

    I’m a huge fan of letting patients make their own medical decisions, unfortunately the system doesn’t offer too much medicolegal support for the shared decision making model. On cases where I use shared decision making I will usually still document that the patient is leaving against my medical opinion. I will tell the patient “My job isn’t to tell you what to do or what decision to make, I’m just here to try to help you and give you the best medical opinion that I can offer.” Patients seem to be pretty receptive to this approach. I then explain “You are technically leaving against my medical advice, but that doesn’t mean that you’ve done anything wrong or made a bad decision.” My hope is that if there is a bad outcome then having them leave “Against medical advice” offers me some legal protection more than if I simply discharged them. Its mostly just semantics, but sometimes in these high risk scenarios, how we say things can really make a difference.

  • njoshi8

    These are two great points that you raise as myths that I also have seen regularly. I think the most important point is to also remain objective. Often in EM we get too emotionally invested, and can take AMA as to mean an attack on ourselves. Keeping the focus on the pt will keep in good accurate documentation. Thanks for a great write up!

  • andygrock

    Great Review Dr. DeLaney. I actually went through the literature myself for my residency’s blog and was surprised at the results – especially after hearing throughout my residency that insurance companies wouldn’t pay for AMA.
    One interesting addition I wanted to present was a case that went to the Arkansas Supreme Court in 1990. A woman left AMA, and Blue Shield denied her payments claiming they had a clause in the contract specifying non-payment in AMA cases. The Arkansas Supreme Court declared that clause was illegal and forced Blue Shield to pay the bill!

  • AZK

    Are there any other differences in patients AMAing from the ED for inpatient? My wife is a hospitalist and I shared this post with her and she wasn’t sure if same rules apply. Specifically medical coverage for hospitalization.

    Thanks.

    • Matthew DeLaney

      I have not seen any literature that supports the idea that visits wouldn’t get covered if a patient leaves AMA, even if they leave from an inpatient bed, but that doesn’t mean it doesn’t happen. I’d be very interested to hear about any specific instances where this happened.