Would you fib for your patient?

Your patient needs a procedure the insurer won't cover. Now what?

By Andis Robeznieks — Posted June 13, 2005

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Your patient needs bypass surgery, but her insurance company says to wait and see if her condition worsens or else they won't pay for the care. Do you fudge and say her condition is a bit more dire than it really is, performing the surgery with the peace of mind that the insurer will cover the cost? Or do you play by the insurer's rules?

About one in 10 physicians said they approve of gaming the system to get patients the treatment they believe is necessary, according to a study, "Lying to Insurance Companies: The Desire to Deceive Among Physicians and the Public," published in the December 2004 American Journal of Bioethics.

Patients are even more comfortable with the idea and might be asking their doctors to embellish symptoms on their behalf.

About one in four people surveyed from the general public approve of a doctor misrepresenting facts to an insurance company under certain circumstances, according to the study author Rachel M. Werner, MD, PhD, and her colleagues.

In the past, experts have described bending the rules for a patient's benefit as "uncommon but far from rare" among physicians, and this most recent study continues to support that characterization. Yet some fear that the practice will grow as patients' insurance policies become less comprehensive and doctors have less time to navigate complicated appeals processes.

The American Medical Association and other medical societies oppose deception regardless of intent. But physicians need to determine how they'll handle patients asking them to fudge the facts because -- as Dr. Werner's research showed -- patients might feel that gaming the system is justified.

"This may be less of an issue today than it was five or eight years ago, but as health care costs escalate, it's going to become an issue again," said Dr. Werner, a staff physician at the Philadelphia Veterans Affairs Medical Center and an assistant professor at the University of Pennsylvania in the general internal medicine division.

Deadline pressures

Dr. Werner's research showed that patients who felt that their physicians were crunched for time and believed that there wasn't enough time to appeal an insurance decision were about four times more likely to support the idea of misrepresenting symptoms to get coverage for necessary care.

While 12% of the public told researchers they supported misrepresenting symptoms if they believed the physician had enough time for the appeals process, the number jumped to 50% when they believed that physicians didn't have the time to appeal.

"Physicians always say they don't have enough time, and the proportion of the public who believe physicians don't have enough time is quite high," Dr. Werner said.

Time also plays a factor in a physician's decision of whether he or she should misrepresent symptoms for the patient. Only 6% of physicians said they would embellish the facts if they felt there was enough time to deal with the appeals process; 13% said they would if there wasn't enough time.

The director of the AMA Institute for Ethics, Matthew Wynia, MD, MPH, agreed that time plays a factor in physician thinking when faced with a difficult professional or ethical decision.

"These decisions involve allocation of scarce resources -- the most common of which is time," Dr. Wynia said. "An individual doctor must care deeply about providing the best care to an individual patient -- but they also have to see all their patients that day."

Getting around a coverage exclusion by explaining less-expensive options or trying to convince a patient to pay for something out of pocket takes time, Dr. Wynia said, and that compounds the ethical dilemma.

"If you have eight minutes to wrap up a visit, do you want to embark on a 30-minute conversation about why they should use drug A vs. drug B?" he asked.

In his own research on physicians manipulating reimbursement rules for patients, Dr. Wynia found that 39% of physicians who responded to the survey said they sometimes exaggerated the severity of patients' conditions, changed patients' billing diagnoses or reported signs or symptoms a patient did not have to secure coverage for needed care.

While these statistics might trouble physicians and insurance companies, Dr. Wynia said the public was "unperturbed" by the findings of his study published in the April 12, 2000, Journal of the American Medical Association.

"A lot of the response was: 'Go doctors, I'm really glad someone's on my side in this crazy health care system,' " he said.

Dr. Wynia compared the public reaction to an audience watching "Les Miserables," in which a man is hounded for the rest of his life for stealing a loaf of bread.

"Everyone in the audience is on the side of the person who stole the bread," he said. "The lesson here ... is not to make thievery legal when the intent is to feed your children, but to look at the social system that forced someone to steal in order to feed their children."

Susan Pisano, spokeswoman for the Washington, D.C.-based industry group America's Health Insurance Plans, though, questioned the level of public support for lying to insurance companies.

She said the reason studies could indicate support for exaggerating symptoms is that surveys use "sanitized language" in framing the question. Instead of using terms such as "deception" or "gaming the system," she recommended that less-benign terms be used and that the consequences of fraudulent behavior be better explained.

"The cumulative effect of this level of deception would be to make everyone pay more for health care," Pisano said. "Someone pays for that [unauthorized] service, and, generally, it's the other policyholders. If consumers and patients thought about what it might mean and it wasn't characterized as a benign activity, I think you would see more opposition from patients."

Some patients might ask their doctors to bend the rules as a test of loyalty, but physicians ultimately need to weigh the consequences of the requests in terms of the negative impact on the health care system and on their own professionalism, Dr. Wynia said. In addition, physicians could face legal problems such as fraud if they were caught falsifying records.

But beyond individual physicians making choices, medical ethicists propose that health plans should examine why some doctors feel the need to game the system in the first place.

Get rid of preauthorization

Oakland, Calif.-based geriatrician and rheumatologist Kate A. Scannell, MD, who serves as regional director for Kaiser Permanente's ethics program, said one way to reduce deception and raise professionalism is to do away with the third-party authorization requirements for tests and prescriptions that physicians find medically necessary.

"Not having to reconcile my professional judgment with contrary and dispiriting third parties unites patients, physicians and the institution on the same 'ethical page,' " Dr. Scannell said. "It also removes several layers of practical obstacles and ethical conflicts from my practice, and it fosters greater efficiency and professionalization."

Pisano said preauthorization requirements are generally linked to treatment that is considered overused or misused, and that preauthorization helps get medicine in sync with the latest science.

The typical reasons coverage for certain treatments could be denied certain patients, Pisano explained, are that their employers did not choose to cover the requested service; the treatment is considered "experimental"; or it's determined that the patient is not an "appropriate candidate" for the requested treatment.

"But when we've looked at the question of coverage determination, in general, the most common reason for not saying 'Yes' to a coverage request is that there is not enough information," Pisano said. "That's the No. 1 reason."

If physicians are misrepresenting facts and choosing to avoid the appeal process because they find it too cumbersome, Pisano advised doctors to work with insurance companies to improve the system.

Dr. Scannell also suggests there would be less deception if people were more "truthful about the truth."

She said medical truth is often "ambiguous, tainted by competing claims, incomplete or weak," so drug companies, researchers, policy-makers, physicians and medical guideline authors who "manufacture or claim" medical truth need to be more transparent.

Better understanding of the nature of medical truth will lead to better informed medical decisions, Dr. Scannell said.

"The question about lying in order to ensure some other good is an old one, indeed," she said. "I suspect that it will continue to thread through our future discussions about health care ethics for a long while to come precisely because it does not produce one consistently obvious or durable answer when asked in the context of other opposing ethical claims."

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Fudging the facts

Patients are more comfortable than physicians with exaggerating symptoms to ensure coverage for a procedure that the physician believes is medically necessary but that the insurer does not define as necessary and covered.

Support misrepresentation

  • Physicians: 11%
  • Patients: 26%

Source: "Lying to Insurance Companies: The Desire to Deceive Among Physicians and the Public," American Journal of Bioethics, December 2004

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Tactical maneuvers

Among 699 physicians surveyed, 39% said they sometimes, often or very often have gotten around a third-party payer's reimbursement rules. Here's a look at how often physicians say they've had to use various methods to ensure that insurers picked up the tab for care they believed was medically necessary.

How frequently, if ever, in the past year have you had to: Very
Often Sometimes Rarely Never
Exaggerate the severity of a patient's condition to help avoid an early discharge from the hospital? 1% 3% 24% 30% 43%
Change a patient's official (billing) diagnosis to help them secure coverage for a needed treatment or service? 1% 3% 19% 30% 48%
Report signs or symptoms that a patient did not have to help him or her secure coverage for a needed treatment or service? 1% 1% 8% 19% 71%

Note: Percentages may not add up to 100 due to rounding.

Source: "Physician Manipulation of Reimbursement Rules for Patients: Between a Rock and a Hard Place," Journal of the American Medical Association, April 12, 2000

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Physician attitudes

Most physicians said it's not OK to exaggerate patients' conditions to third-party payers so that insurers will pay for procedures. Other findings from the survey of 720 physicians include:

  • 15% said, in general, it is ethical to game the system for a patient's benefit.
  • 29% said it is necessary to game the system to provide high-quality care.
  • 37% said patients had requested that they deceive third-party payers.
  • 56% said worries about fraud prevent them from exaggerating patients' conditions to payers.

Source: "Physician Manipulation of Reimbursement Rules for Patients," Journal of the American Medical Association, April 12, 2000

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