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Doctors Say They Deceive Insurers to Help Patients

Associated Press, April 12, 2000; Page A11.

More than a third of doctors surveyed nationwide admit deceiving insurance companies to help patients get the care they need. Their tactics include exaggerating the severity of an illness to help patients avoid being sent home early from the hospital; listing an inaccurate diagnosis on bills; and reporting nonexistent symptoms to secure insurance coverage.

In a random mailed survey of 720 doctors nationwide in 1998, 39 percent said they had used at least one of those tactics "sometimes" or more often within the preceding year.

The results were published in today's Journal of the American Medical Association.

Thirty-seven percent said their patients "sometimes" or more often asked them to deceive insurers. More than a quarter--28.5 percent--said it is necessary to "game" the system to provide high-quality care.

Of the doctors who reported using deceitful practices, 54 percent said they did so more often than in the past.

"As pressures to control health care costs increase, it is likely that manipulating reimbursement systems will increase," wrote the researchers, led by Matthew K. Wynia of the AMA's Institute for Ethics in Chicago.

"Health plans in which the use of these tactics is common should carefully review their rules and procedures and work with physicians to reduce the perceived need for covert advocacy."

Charles M. Cutler, chief medical officer for the American Association of Health Plans, which represents more than 1,000 HMOs and other insurance plans, said doctors who deceive insurers are "essentially allowing people to get benefits for which they haven't paid."

"The people who pay for that are everybody else who's paying for the premiums," Cutler said.

A smaller survey published in the AMA's Archives of Internal Medicine last year found that more than half of doctors approved the use of deceitful practices with insurance companies. The authors of the latest survey said theirs is the first to report what doctors are actually doing.

Although doctors were not asked why they engaged in deception, the researchers suggested such reasons as managed-care restrictions and patients' demands.

An accompanying editorial said Wynia's study provides the most reliable information to date on the extent of such deception. The practice may result in part from the public's contradictory expectations of wanting costs contained but demanding access to the finest health care and expecting "their physicians to be faithful, uncompromising agents," wrote M. Gregg Bloche of the Georgetown-Johns Hopkins University Program in Law and Public Health.