Who Drives a Patient's Treatment: The Treatment Team or the Insurance Company?

When it comes to a patient's treatment, it's important to consider multiple factors. While the medical necessity criteria of an insurance company can certainly play a role in the decision-making process, the treatment team ultimately bears the responsibility of creating a plan that prioritizes the patient's needs. So which takes priority? Will a facility continue to provide care for a patient when their insurance company will no longer authorize the stay? There is a balance here where the facility should try to do what is right by the patient clinically while considering the financial complexities. Treatment goals and objectives are also taken into account, as the team works to create a plan that will set the patient up for success. While navigating the complex world of healthcare can be challenging, a thoughtful approach that prioritizes the needs of the patient can go a long way in finding the best possible outcome.

A lot will be said about the efficacy of a facility when an insurance company denies the approval of care and the facility does not feel as though the patient is safe to be discharged. Discharging a patient comes with clinical risk while keeping the patient comes with financial risk. The decisions in these scenarios are not easy but they are important.

As a patient, how do you navigate the priority of accomplishing your goals given that both the treatment team and insurance often have differing opinions?

Do you feel you are adequately informed when it comes to your treatment plan, and that your preferences are taken into account?

From an administrative standpoint, what compromises have to be made when working with a patient's insurance provider in order to ensure effective treatment?

What role does patient advocacy play in determining treatments which will best benefit patients and their conditions?

How does the system of third-party payments affect decisions concerning which treatments are available for patients?