Doctors Willing to Deceive Health Plans for Patients

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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.

Suggesting a possible link with increasingly aggressive managed care cost-control practices, more than half of these physicians said they gamed the system more frequently than they had five years earlier. Yet 61% of physicians said that they rarely or never manipulated payment rules.

Additional survey questions revealed that doctors' willingness to manipulate health plan rules was strongly linked to their belief that such behavior was necessary to provide high-quality care. Almost 29% of the survey's physicians thought it necessary to game the system to provide high-quality care. Nevertheless, just over 15% of the physicians in the survey said that they believed it was ethical to do so.

"They are being asked to do something that they believe is unethical in order to do a good job," Wynia tells WebMD.

But Young disagrees, saying "there is no question in the research literature that 20% or more of health care services are unnecessary. Doctors are doing whatever they can to lash out against managed care."

Of the doctors surveyed, 37% reported that patients had requested that they deceive their health plan, a factor that Wynia says correlated strongly with physicians who reported that they gamed the system. And doctors who said that they had insufficient time with their patients also were more likely to engage in deceptive practices.

Young notes that this deception by doctors brings "potential harm" to patients. "If you put something on a medical record, a diagnosis that is not accurate, the individual then could have that diagnosis carried with them," he tells WebMD. "If you put down diabetes when in fact they don't have diabetes ? it may interfere with their getting life insurance."


While doctors may be deceptive, they do not necessarily deceive for greed. "Physicians with potentially greater financial stakes in manipulating reimbursement rules did not report doing so more often," the authors write.

The problem isn't likely to get better anytime soon, as cost-control pressures are certain to only intensify in the health system, the study notes. But the survey "may stimulate more scrutiny of physicians and physician claims," says Young. "This just lays out that there is substantial fraud going on out there."

"There is a fundamental conflict here and neither society nor doctors have a clue as to how to answer it," Georgetown University law professor Gregg Bloche, MD, JD, tells WebMD. "The conflict is between ? the notion that physicians have a duty of undivided loyalty to patients, and the 20th and 21st century reality that health care is much too expensive to be paid for by individual folks out-of-pocket."

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