Journal of General Internal Medicine

, Volume 27, Issue 7, pp 825–830 | Cite as

Financial Responsibility of Hospitalized Patients Who Left Against Medical Advice: Medical Urban Legend?

  • Gabrielle R. Schaefer
  • Heidi Matus
  • John H. Schumann
  • Keith Sauter
  • Benjamin Vekhter
  • David O. Meltzer
  • Vineet M. AroraEmail author
Original Research



Physicians may counsel patients who leave against medical advice (AMA) that insurance will not pay for their care. However, it is unclear whether insurers deny payment for hospitalization in these cases.


To review whether insurers denied payment for patients discharged AMA and assess physician beliefs and counseling practices when patients leave AMA.


Retrospective cohort of medical inpatients from 2001 to 2010; cross-sectional survey of physician beliefs and counseling practices for AMA patients in 2010.


Patients who left AMA from 2001 to 2010, internal medicine residents and attendings at a single academic institution, and a convenience sample of residents from 13 Illinois hospitals in June 2010.


Percent of AMA patients for which insurance denied payment, percent of physicians who agreed insurance denies payment for patients who leave AMA and who counsel patients leaving AMA they are financially responsible.


Of 46,319 patients admitted from 2001 to 2010, 526 (1.1%) patients left AMA. Among insured patients, payment was refused in 4.1% of cases. Reasons for refusal were largely administrative (wrong name, etc.). No cases of payment refusal were because patient left AMA. Nevertheless, most residents (68.6%) and nearly half of attendings (43.9%) believed insurance denies payment when a patient leaves AMA. Attendings who believed that insurance denied payment were more likely to report informing AMA patients they may be held financially responsible (mean 4.2 vs. 1.7 on a Likert 1–5 scale, in which 5 is “always” inform, p < 0.001). This relationship was not observed among residents. The most common reason for counseling patients was “so they will reconsider staying in the hospital” (84.8% residents, 66.7% attendings, p = 0.008)


Contrary to popular belief, we found no evidence that insurance denied payment for patients leaving AMA. Residency programs and hospitals should ensure that patients are not misinformed.


patient discharge financial responsibility hospital reimbursement 



We would like to acknowledge Debra Massi for facilitating contact with billing and clarifying data, Kimberly Beiting, Meryl Prochaska, and Paul Staisiunas for their administrative support, the Pritzker Scholarship and Discovery Quality and Safety Track and Pritzker Summer Research Program for encouraging this research.


We would like to acknowledge funding from AHRQ CERT Grant 1U18HS016967-01and NIA T35 Grant 5T35AG029795-02.

Prior Presentations

This research was presented as a poster at the 2011 American College of Physicians Meeting, April 8–10 in San Diego, CA, and the 2011 Society of Hospital Medicine Meeting, May 11–13 in Dallas, TX.

Conflict of Interest

Gabrielle R. Schaefer reports no potential conflict of interest. Heidi Matus reports no potential conflict of interest. John H. Schumann reports no potential conflict of interest. Keith Sauter reports no potential conflict of interest. Ben Vekhter reports no potential conflict of interest. David O. Meltzer reports a consultancy position at the Congress and Budget Office and grants from the NIH, RWJ, and AHRQ. Vineet Arora reports grants from the NIA, AHRQ, ACGME, and the ABIM Foundation.

Statement of Exemption

This study was determined to be exempt by the University of Chicago Biological Sciences Division Institutional Review Board.

Supplementary material

11606_2012_1984_MOESM1_ESM.doc (63 kb)
ESM 1 (DOC 63 kb)


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Copyright information

© Society of General Internal Medicine 2012

Authors and Affiliations

  • Gabrielle R. Schaefer
    • 1
  • Heidi Matus
    • 2
  • John H. Schumann
    • 3
  • Keith Sauter
    • 4
  • Benjamin Vekhter
    • 5
  • David O. Meltzer
    • 5
  • Vineet M. Arora
    • 2
    • 5
    Email author
  1. 1.Pritzker School of MedicineUniversity of ChicagoChicagoUSA
  2. 2.Internal Medicine Residency ProgramUniversity of ChicagoChicagoUSA
  3. 3.Department of Internal MedicineUniversity of Oklahoma School of Community MedicineTulsaUSA
  4. 4.Patient Financial ServicesUniversity of Chicago Medical CenterChicagoUSA
  5. 5.Department of MedicineUniversity of ChicagoChicagoUSA

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