NCPA - National Center for Policy Analysis

Physicians Lie To Get Procedures Covered

March 1, 2000

Several studies have shown that physicians are willing to either exaggerate a patient's condition or fabricate a diagnosis if it means a plan will pay for a procedure, especially if it's a clearly necessary procedure such as heart surgery.

In one study, researchers asked 169 internists whether they would advise a colleague to lie to a patient's insurance company to ensure the patient was covered for a particular service.

  • Of those surveyed, 58 percent said they would sanction deception to get coronary bypass surgery approved.
  • This was followed by arterial revascularization (56 percent), intravenous pain medication and nutrition (48 percent), mammography (35 percent), and psychiatric referral (32 percent).
  • Only 2.5 percent said they would sanction deception in the case of cosmetic rhinoplasty, and 27 percent did not support deception under any of the scenarios presented.

The fact that physicians will sanction lying or exaggerating to get a needed procedure covered by a managed care plan means there's something seriously wrong with the health care system, experts say.

The news findings are similar to those of two other recently released studies.

  • The first one, by the American Medical Association's Institute for Ethics, showed that 28 percent of 724 physicians surveyed had exaggerated the severity of patients' conditions to avoid early discharge from the hospital, and 23 percent had changed billing diagnoses to help patients secure coverage.
  • A second study, released in July by the Henry J. Kaiser Family Foundation, showed that 48 percent of 1,053 doctors surveyed had exaggerated their patients' conditions for coverage purposes in the last 2 years.

Source: Joyce Frieden, "Physicians Willing to Lie to Get Procedures Covered," Clinical Psychiatry News, January 2000.


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