How to handle insurer requests for more information on patients' pre-existing conditions

THE CHALLENGE:

Is a physician obligated to complete insurance forms that could be used to deny coverage to his patients?

"The forms are obviously designed to help the insurance company deny a claim based on pre-existing conditions," Sacco says. Completing the forms typically requires Sacco to comb through years of records and cross-reference ICD-9 codes. What's more, Sacco says the forms contain a warning that erroneous information may be considered "fraud."

"It would be hard for support staff to fill out the forms, as they require knowledge of ICD-9 codes, and ultimately when being confronted with the word 'fraud,' you generally want to check something yourself," he says.

Sacco wonders if he's obligated to fill out the forms, particularly since the result could be financially harmful to his patients.

THE SOLUTION:

From a legal standpoint, Sacco probably isn't under any obligation to respond to the insurer's request, as it's unlikely state laws would cover the matter, says Steven I. Kern, JD, a healthcare attorney with Kern Augstine Conroy & Schoppman in Bridgewater, New Jersey.

But if he wants to get paid by the insurer, it's another story. "Since the inquiry seems to be related to payment for services, it's likely that the carrier has a right to this information before determining if the services are covered and payment is due to the physician," Kern says.

Or, to put it more succinctly: "If the doctor does not respond, he probably will not get paid," Kern says.

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