Many medical professionals believe that if they don’t strictly follow treatment guidelines, their patients won’t receive approval from their insurance companies for the treatment. This sparks a strong backlash from some physicians who believe the guidelines interfere with their ability to exercise professional judgment. “Medicine is not a cookbook,” they say. What should physicians do when their medical recommendations diverge from evidence-based treatment guidelines?
Guidelines Capture the Best Shared Expertise
Guidelines exist to help physicians provide the most efficient and cost-effective care. Evidence-based guidelines, in particular, have evolved out of science and the shared knowledge and research of medical experts in many fields.
There will always be circumstances in which medical professionals have to put aside the guidelines and use their professional judgment. A certain treatment may not be appropriate for a patient because he or she has had an adverse reaction to it in the past, or has a co-existing health condition that would be exacerbated by the remedy in question.
Help the Reviewer Understand the Treatment
To receive approval for treatment, physicians must be able to explain why they are recommending a specific regimen or procedure versus another. Physicians should provide the reviewer with documentation that explains why the requested treatment is medically necessary.
When reviewers understand the medical theory and decision-making process for recommending a treatment, it is easier for them to approve a request that strays from guidelines. Guidelines are there to aid physicians, not hinder them; they are not absolute and with proper documentation, they can be flexible.
Work With Guidelines, Not Against Them
Guidelines are like a cookbook: Just as people sometimes fine-tune their favorite recipes, guidelines provide a structure that can be modified. As physicians become more experienced with guidelines, they recognize when and how they should deviate to best care for each patient. Good physicians rely on a combination of their own medical expertise and the most reliable evidence; neither is sufficient in isolation.
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