Patients 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 . 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 . 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”. 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 . 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.
- 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
- 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
- Dedely v Kings Highway Hospital Center, 617 NYS 2d 445 Supp, 1994.
- 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).