Should Medical Insurance Review Serve the Patient’s Best Interests? Examples and Considerations Illustrated by Behavioral Health Cases

Abstract

Physician medical directors working for health care insurance companies conduct utilization reviews, participate in quality-of-care reviews, and adjudicate appeals. As a result, they have access to substantial and important clinical information. The medical director may have both current and historical information that can assist the treatment team in providing care. Sharing this information with a patient’s current health care provider(s) is problematic due to concerns about patient privacy and the insurer’s goal of not assuming legal liability for patient care. While this paper considers legal issues, it predominantly addresses the ethical responsibilities of medical directors who have valuable information unavailable to or unrecognized by the treatment team. Although it is important to consider sharing general medical information, this paper emphasizes the sharing of behavioral health information, which can be highly sensitive but also pertinent to psychiatric and other medical treatment choices. We suggest that clinical information should flow from insurer to provider when the insurer has information that will benefit the patient or prove crucial to optimal care rather than just flow from provider to insurer for the purposes of claims payments. To support and secure that flow, the paper outlines procedures for determining the need to share information, the means of providing that information, ways to separate liability, and processes for protecting privacy.