Billing and Collections: You Are Being Watched? The diagnosis you make today could be held against patients tomorrow by insurers<

by: Laurie Hyland Robertson

Have you ever had a patient ask you to leave a diagnosis or prescription out of his medical chart? Odds are you have. And if not, you probably will soon.

The reason: That diagnosis or prescription could ultimately prevent the patient from buying health insurance.

As you likely know, the U.S. insurance industry relies on an extensive network of patient data when making decisions about whether to insure people purchasing policies on their own. So that prescription for, say, Zoloft could prompt an insurer to reject Jane Doe’s application for coverage in years to come because of a pre-existing condition.

Now a growing number of American consumers are becoming aware of this practice, too. Many are responding by asking physicians to deliver care that’s off the chart, so to speak.

How can a conscientious doctor respond to a patient worried that a treatment he needs may come back to haunt him?

David Kibbe, a physician with an MBA, would certainly like to know. He wonders about the limits on legally permissible uses of information that a health plan might have on a patient, suspecting that “rather large loopholes” in public policy allow for either unethical or discriminatory applications of personal health information. Denying coverage on the basis of a previous mental illness — perhaps one deduced from a medication list — is of course blatantly discriminatory. But as part of payers’ risk-assessment process (“cherry picking,” in less-charitable language) and accepted pre-existing condition disqualifications, it’s perfectly legal.

The renowned patient privacy advocate Deborah Peel warned Congress that this and worse would happen if they approved a proposed amendment to HIPAA in 2002, effectively eliminating requirements for patient consent to information sharing. “Health plans will gain open access not only to the results of a few diagnostic drug and urine tests performed in hospitals and to patient communications about sexual orientation with their physicians, but to all the genetic and medical records of every citizen of this nation,” the psychiatrist testified at the time. “Access to all past and future medical records, in every place where patients receive (or received) medical care, will be permitted by over 600,000 covered entities, business associates of those entities, and all their employees.”

A little over the top, perhaps, and many groups, including insurers, certainly have good reasons for wanting to access patient records. However, setting aside concerns about biases against mental health parity, “Every week there is a story of a security breach in a medical record system,” says New Jersey psychiatrist Robert Bransfield. “Once information enters these databases, who knows where it will go?” Or how they might use it. Electronic health records, e-prescribing, and online physician-patient communication will only add new wrinkles to these scary scenarios.

What’s the deal?

Bransfield knows many stories of patients being turned down or put in higher<

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