How to Avoid Getting Blamed for Health Insurers' Actions

Tips to avoid a lawsuit or board allegation due to a patient unhappy with a health insurer's decision.

Risk Management

How to Avoid Getting Blamed for Health Insurers' Actions

If you're like many Doctors of Chiropractic, you have patients who are unhappy about the way their health insurers reimburse for chiropractic services. They may even fault you for not intervening on their behalf. Here are tips to avoid a lawsuit or board allegation as a result of a patient who is unhappy with a health insurer's decision.


This can become a significant risk management issue for your practice because an unhappy patient—no matter what the reason—is more likely to sue or file a grievance with your board. In addition, if you’re like most D.C.s, you can’t afford to lose patients due to dissatisfaction with your office practices.

So, What’s a Doctor to Do?

While no one can be expected to remember all the requirements and coverages of the health plans with which the practice is affiliated, the following steps can help improve patient satisfaction and your practice’s risk management. As a bonus, you’ll also save time, improve efficiencies and speed insurance claims turnaround.

  • Designate a staff member to be the patient’s advocate with third-party payers. This person must be knowledgeable about the plans accepted by your practice and how to work within the system. For example, knowing what information each insurer requires for specialist referrals will help make the referral process more efficient. This person also needs the appropriate demeanor to work with patients and insurers alike—someone who can keep a cool head during what may be heated, emotional discussions. One caveat: If this person is out of the office, your “human database” of knowledge also will be unavailable.
     
  • Have insurance plan requirements and coverages readily available. This doesn’t need to be extensive but can be a brief summary of each plan's approved labs, imaging facilities, referral information, precertification requirements, copays and any unusual coverage exclusions, and billing procedures or requirements. Review and update this information regularly, making changes and updates as needed. 
     
  • Develop charts or spreadsheets listing the coverages offered by the primary plans with which the practice is affiliated, especially for frequently ordered procedures, tests and medications. The time you spend to create and maintain these guides will be well worth it because it will help the patient know what is covered.  
     
  • Educate your patients on their insurance coverage requirements. Patient brochures can be useful for this. Do patients need precertification for some procedures or treatments? What laboratories or testing facilities are used and are they in the patient’s network? Who should patients contact with billing or insurance questions?
     
  • Contact the insurance plans and request copies of their member materials to keep on hand. Ask them for advice on how the practice can better process claims for the plan’s members. Find a contact person at each insurer who can be called routinely when problems arise.

Helping your patients become better informed about what to expect from you, the practice and their insurance plans will help them view your practice as an advocate for their healthcare needs, resulting in greater patient satisfaction and less risk to your practice.


The information in the NCMIC Learning Center is offered solely for general information and educational purposes. It is not offered as, nor does it represent, legal or professional advice. Neither does this information constitute a guideline, practice parameter or standard of care. You should not act or rely upon this information without seeking the advice of an attorney familiar with the specific legal requirements of the state(s) in which you practice. If there is a discrepancy between the site and an insurance policy you have with NCMIC, the policy will prevail.