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Doctors Willing to Deceive Health Plans for Patients

WebMD Health News

April 11, 2000 (Washington) -- Is it OK for your doctor to fudge health information in order to help you get your treatment covered by your health insurance plan? The practice certainly seems widespread, new findings indicate.

Nearly 40% of physicians surveyed say they had "gamed" health plan payment rules to get coverage for services they thought were medically necessary, according to survey results reported in the April 12 issue of today's Journal of the American Medical Association (JAMA).

"We have shown the results of a real moral stress test," says Matthew K. Wynia, MD, MPH, co-author of the study and vice president of the American Medical Association's Institute for Ethics. "Physicians feel stuck between obligations to their patients on the one hand and obligations to enforce insurance coverage contracts on the other."

"When push comes to shove, many [doctors] don't feel like it's appropriate to be strict enforcers of insurance contracts, but rather to be merciful toward their patients and let them out of the contract," Wynia says. However, he warns, "There are things that need to be done to help patients out, but getting it done this way, is ? leading us in the wrong direction."

Don Young, MD, chief operating officer and medical director of the Health Insurance Association of America, says he is "very troubled" by the findings. "As a physician, I find nothing in here that makes me proud of the profession," he tells WebMD. "They are saying that they are doing this out of the ethical responsibility to their patients, ? [but] miscoding charts, perhaps committing fraud, and taking funds that are not appropriate for that patient is not ethical behavior."

Previous peer-reviewed studies have revealed physicians' theoretical willingness to disregard coverage rules, but the JAMA report is the first to measure actual doctor behavior.

The report is released on the heels of an announcement by Aetna U.S. Healthcare saying the HMO will discontinue its "doctor reward" program as part of a settlement in a lawsuit filed by the State of Texas. In a deal that could become a model for other HMOs, the settlement finds that Aetna can no longer offer financial incentives to physicians who limit necessary care to HMO members in order to stay within budgets.

The announcement, which is a step toward giving doctors more control over the decisions they make regarding your care, could also be a step toward reducing the widespread gaming that was reported in the JAMA survey.

In that national survey, 720 doctors were asked whether in the last year they had "sometimes" -- or more frequently -- exaggerated a patient's condition, changed a billing diagnosis, or reported symptoms that were not present. Some 39% of the respondents reported that they had done so to gain payment for services that they believed were necessary.

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