Docs Fudge Facts to Insurers to Get Coverage

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Docs Fudge Facts to Insurers to Get Coverage

Tue May 28, 3:14 PM ET

By Alison McCook

NEW YORK (Reuters Health) - Physicians sometimes fudge information about a

patient to an insurance company in order to work around situations in which

coverage is typically denied.

Now, US researchers have found that doctors are more likely to lie if they

believe they are less likely to win an appeal against the denied coverage,

and if the appeal process is lengthy and burdensome.

" Our findings support that there is a tension that exists between the

complex healthcare environment with escalating costs and the pressures to

contain those costs, and the responsibility that physicians feel to

represent their patients' best interests and obtain necessary care, " lead

author Dr. M. Werner of the University of Pennsylvania in

Philadelphia, told Reuters Health.

Physicians will sometimes " game the system, " as Werner called it, when they

feel a patient needs a test, treatment or referral that the insurance

company normally does not pay for in other patients with similar

circumstances. To remove this obstacle, doctors may lie to the insurance

company about the patient's condition--perhaps exaggerating the severity, or

adding additional symptoms. In some cases, doctors may change the billing

diagnosis.

Physicians can also appeal the insurance company restriction, a process that

involves calling the insurance company and trying to convince them the

procedure is needed.

In an interview with Reuters Health, Werner said that some services that

physicians may deem medically necessary but are restricted by insurance

companies include using newer, more expensive medications instead of generic

or cheaper brands. Sometimes physicians may also want to use a diagnostic

test to screen patients for certain diseases, such as prescribing a

bone-scanning procedure to screen asymptomatic women for osteoporosis, which

is only covered for diagnosing women with symptoms of the disease.

To determine how often physicians work around insurance company

restrictions, and when they choose to do so, Werner and her colleagues

evaluated 1,617 mail-in surveys from physicians about what they would do in

different patient scenarios.

In one scenario, a patient wants heart bypass surgery for chest pain, but

the insurance company won't cover it because the pain has not increased in

months. In the other situation, a patient with low back pain requests an MRI

after 4 months of pain, but his insurer will only pay for the procedure

after 6 months of pain.

The investigators found that most physicians--77%--would appeal the

typically restricted but medically necessary services. Some said they would

simply accept the restrictions, but 11% said they would misrepresent a

patient's condition to work around the limitation.

In the May 27th Archives of Internal Medicine (news - web sites), Werner and

her team also noted that physicians were more likely to lie in order to work

around restrictions if there was a lengthy appeals process, the chance of

succeeding with the appeal was low and the patient was in relatively bad

shape.

Werner said that doctors' attempts to work around insurance restrictions are

not cases of an " us-versus-them " scenario. Healthcare costs are rising, she

said, and insurance companies have the difficult job of containing them.

" Sometimes this forces them to make decisions such as restricting access to

healthcare. Inadvertently, the restricted care is sometimes necessary care, "

she said.

To solve these obstacles, " physicians and insurers must operate together, "

Werner recommended.

SOURCE: Archives of Internal Medicine 2002;162:1134-1139