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Sunday, April 15, 2007

Doctors Might Lie to Insurers to Avoid Hassles

One in 10 doctors say they would lie about a patient's condition to obtain approval from an insurance company for that patient's surgery or other medically necessary treatment, according to researchers from the University of Michigan. And that number climbs when doctors consider the potential "hassles" about HMO approvals.

In a paper published May 17, 2002, in the Archives of Internal Medicine , the researchers report that 11 percent of 890 randomly surveyed physicians say they would "misrepresent" a patient's medical condition to insurers to secure HMO approval for surgery or additional procedures. That number rose to 13 percent when physicians were told the appeal process for a treatment denial would only be 50 percent successful, as opposed to 9 percent when told that the appeal success rate was 95 percent.

Additionally, although 9 percent of the doctors say they would misrepresent a patient's condition if the appeal process was estimated to take 10 minutes, that number increased to 14 percent if they were told the appeal would take 60 minutes. The number who said they would lie is highest (16 percent) when doctors factor in a patient whose condition is "severe."

"The 'hassle factor' had a big influence over the doctors' actions," says Dr. Peter A. Ubel, associate professor of internal medicine at the University of Michigan Medical School and research investigator at the Ann Arbor Veterans Administration Medical Center. "If the HMO says 'no,' doctors can appeal, but often, it is a long and burdensome process. So in some cases, physicians lie about their patients' condition."

This news is troubling to the American Association of Health Plans, says spokesperson Mohit Ghose. "You've got to deal with the implications of outright lying," Ghose says. "What happens when a patient switches doctors and the medical record does not reflect the patient's true health history?"

According to Ghose, 41 states and Washington, D.C., have emergency external review laws that require expedited reviews of denials within 72 hours. "There are mechanisms in place to address treatment denials," he says.

Us vs. Them

Although there is plenty of animosity between insurers and doctors these days, Ubel says it's important not to view his study results as an "us vs. them issue." He is calling for increased cooperation between the two, a sentiment that is echoed by Ghose.

"There is going to have to be more cooperation between the two," Ubel says. "It's clear some doctors will lie to get what they want when confronted with approval hassles. But the doctors' goals should be the same as the insurance companies' - to control costs while at the same time encouraging evidence-based medicine and more reliable [treatment] behavior."
Ghose agrees. "It's got to be a partnership between the two. Doctors and health plans must work together to responsibly provide the access to the health care that patients need while following the [health insurance] contracts signed by employers."

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