Consent key for insurance information requests

Clinicians should seek legal advice when in doubt about information requests from insurance companies concerning their patients, says Elyse Sunshine.

Sunshine tells there are a number of contexts in which insurers might contact health-care professions of various stripes for information about their patients or their patients’ files, including:

  • medical assessments as part of a claim by the insured patient
  • audit of insured patient’s past claims for accuracy
  • audit of health provider’s past treatments

When the health professional or the clinic itself is the subject of an insurer-led audit, Sunshine says there may be a way to turn over the necessary documentation while anonymizing individual patient details.

Insurers may ask for documents with patient names blocked out, depending on what they’re looking into,” she says. “But health professionals should seek advice as to whether they have the authority to release that information, whether it contains identifying information or not, as they may need patient consent depending on the specific situation.”

In general, Sunshine says patient consent is key to any request.

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