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What is "Standard of Care" and how does it affect your wallet?

By Martine G. Brousse

"The Medical Bill Whisperer"

Patient Advocate, Certified Mediator



January 25, 2024


what is Standard of Care and what does it mean for your wallet?
what is Standard of Care and what does it mean for your wallet?


“Standard of care” affects your medical care at every level as well as your wallet.

Are you aware of what it means, and what it costs you?


“Standard of care” depends on who is referring to it.




The standard of care is the benchmark that determines whether professional obligations to patients have been met(Vanderpool D. The Standard of Care. Innov Clin Neurosci. 2021 Jul-Sep;18(7-9):50-51. PMID: 34980995; PMCID: PMC8667701)


It is based on State and Federal laws and mandates, as well as opinions from legal cases.


Failure to meet this “standard of care” means Malpractice, a major actor in healthcare.




It is usually acknowledged to be as the “level of care, expertise and treatment which, along with all relevant circumstances, is recognized as acceptable and appropriate by reasonably judicious health care providers of similar practice


This can be interpreted as: the level of care that another physician would provide, based on the same circumstances and based on similar knowledge, training, experience and skills.




It is the guidelines, determinations and policies that have been published, proven, approved, established by:

·      The FDA

·      State and Federal Health Agencies such as the CDC and HHS,and the Center for Medicare and Medicaid Service

·      Professional Medical Associations and Societies

·      The American Medical Association

·      Accreditations Standards

·      Specific hospitals or facilities when rendering services within their location

A good example is the NCCN Compendium (National Comprehensive Cancer Network) which compiles scientific information about the appropriate use of drugs and biologics in cancer patients, and is considered Standard of Care in oncology.




Standard of care is established in Medical Policies which must be followed in order to guarantee coverage and payment.

Medical Policies are proprietary and do not need to reflect other policies or guidelines, although they mostly do.

Medical Policies can vary among insurers, one being more generous than another, or more current.




1.     Legal POV

·      Fear of malpractice haunts medical providers and directs their actions: negligence, misdiagnosis, harm even patient death

·      A tendency to overestimate the risk of rare events leads to risk management behavior, at the expense of scientific rationale

·      This leads to “Defensive Medicine”, ruling out potential outcomes instead of making a straight diagnosis

·      This behavior has led to much more diagnostic testing, more referrals and consultations, aggressive interventions, including more hospital admissions and post-acute care use.

·      For patients, more services means paying more $


2.     Medical POV


·      Following “Conventional traditional medicine” is the norm

·      This means adherence to established protocols, reluctance to go outside the norm, blind reliance on guidelines and regulations, distrust of alternative options, advocating intervention over lifestyle changes, having limited knowledge and use of other medicinal methods (such as nutritional supplements, naturopathy, acupuncture etc)

·      For patients, more affordable, less aggressive options may not be available or proposed


3.     Clinical POV


·      What is called “Local Medicine” becomes Standard of care. Location is the determining factor: Rural vs. Urban. It seems obvious that rural care will not meet the same standards as in urban areas:

·      In rural areas, the PCP often acts as a multiple-specialty specialist

·      Prompt and close by access to specialty care is difficult if at all possible

·      The availability of supportive services (infusion centers, labs) and equipment (imaging centers, dialysis machines) is often limited

·      Insurance benefits can be lower, further reducing access and action

·      As the cost is the number of services, limited care means lower costs. But at what health cost?


4.     Insurance POV


Medical policies determine coverage and therefore payment, however obsolete or updated they may be.


Insurance may alter treatment, force a specific (cheaper) option or even deny based on criteria such as cost, or lack of supportive medical justification. If “medical necessity” does not meet the requirement of the policy, an authorization or claim is likely to be denied.


F.    A point of hope


A “standard of care” is a fluid term, it can be altered, updated or contest based on new evidence, published documentation and articles, updated guidelines and protocols, other insurers’ policies, legal opinions and articles by health agencies.


You and your medical provider have the right to appeal any rejection or denial (claim or authorization). Proving a medical policy is obsolete should help you win any appeal.




Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.


@martine brousse 2024  @ the medical bill whisperer 2024

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