Search

The following provides a general description of the more common types of insurance forms and a recommended fee for each.

Bear in mind that you are not obligated to charge these recommended fees. You may choose to charge an alternate fee, or to determine your fee based strictly upon your hourly rate (see note).

Attending Physician’s Statement — Fee $100

Completion of this form is requested by insurance companies after clients have applied for insurance coverage and have provided the company with information on their medical history (and other biographical data). This form is usually sent directly to the physician (accompanied by the patient’s signed consent form) and is a request for historical medical information directly from the patient’s medical charts. The physician’s findings, treatment, and opinion recorded following a patient’s visits for significant medical problems are requested.

Insurance companies do not generally require that a medical assessment be performed on the patient since this is not a request for information on the patient’s current health status. This is not the case in the event the patient is putting in a disability claim. In that case, the insurance company may require a medical assessment and up-to-date information on the patient’s health status.

Relevant copies of lab test results and/​or electrocardiograms may also be requested by the insurance company.

System or Disease Specific Questionnaire — Fee $75

This form is usually sent directly to the physician (along with the patient’s signed consent form). The questionnaire will ask for specific details related to a patient’s medical condition.

For example, in the case of a patient with diabetes, past blood sugar reading, treatment given, control details, etc. would be requested. Unless specifically requested, a medical assessment is not required to complete this form since it is not a request for a report on the patient’s current medical status.

Insurance Medical Examination — Fee $215

This is a request by the insurance company for a general physical examination and completion of the corresponding form. It usually includes questions making up a functional inquiry, a past history of the patient’s health status and the results of the physical examination.

System Specific Examination — Fee $94.50

This is a request by the insurance company for an assessment that includes a single system medical history and examination. It includes a review of the pertinent medical history relating to the system, a system specific examination and the completion of the corresponding form.

Clarification Report — Hourly Rate

This report is usually requested directly from the physician to adjudicate a claim. It involves answering specific questions to clarify information about medical and administrative details previously submitted to the insurance company. A medical examination is not usually required unless specifically requested by the insurance company.

Full Narrative Report — Hourly Rate

This report is usually requested by the insurance company. The physician is asked to answer detailed questions to clarify information about medical and administrative details. This is quite common in cases of prolonged or complex disability (such as chronic fatigue syndrome) or psychiatric illness as many disability policies have a higher standard for the payment of benefits past a certain time (e.g., two years).

Narrative reports are usually requested in a letter-type format, and insurance companies usually require that copies of appropriate test results and consultation reports also be included with the response. A medical examination is not usually required unless specifically requested by the insurance company.

Independent Medical Examination — Fee — Variable

This is a request by an insurance company for a second opinion” regarding a claimant who is not your patient. Fees for independent medical examinations are usually contracted between a physician and an insurance company. Fees should be discussed in advance of providing the service, and will vary, based on the insurance company’s requirements and the type of report that is requested.

Note on Agreements to pay:

Regardless of whether you elect to charge the fees recommended in this guide, or some other fee, it is advisable to communicate to the insurance company in advance of preparing your report what your fee will be, and to obtain the insurance company’s consent (preferably written) to pay the fee.

In some cases, the insurance company will indicate that it is not prepared to pay the full amount of the fee you quoted, and is instead, prepared to pay only a lesser amount. In such cases, you should advise your patient, before providing the service, that he/​she will be responsible for the difference between the total amount of your fee, and the amount that the insurance company is willing to contribute toward the fee. You should also, before providing the service, ask the patient to provide you with their written agreement to pay this amount to you.

Requests from Patient

This applies in BOTH of the following cases:

  1. The patient attends at your office and requests that a medical report/​information be provided to his/​her insurance company.
  2. The insurance company sends you an authorization, signed by the patient, to provide the insurance company with a medical report/​information, and the authorization states the patient is to be responsible for the costs of the service.

In either case, inform your patient (preferably in writing):

  1. That there will be a fee for the service;
  2. What that fee will be; and
  3. That before you prepare the medical report/​information you require written confirmation that the patient will pay your fee promptly after delivery of the medical report/​information to the insurance company.

Suppose your patient takes issue with whether they (as opposed to the insurance company) should be responsible for the fee’s payment. In that case, advise your patient that this is a matter to be worked out directly between the patient and the insurance company. Ask your patient to contact you after discussing the matter with their insurance company to advise you of the outcome. After that, follow the appropriate steps set out above.

For guidance on providing reports and forms in a timely manner, click here.

Last updated
September 12, 2022