NCPA - National Center for Policy Analysis

Are Doctors Lying To Get Patients Covered?

November 11, 1998

Observers are troubled by evidence that managed care is leading some doctors to "lie, fudge facts or otherwise game the system to get patients necessary medical care." But providers of managed care -- health plans that use so-called gatekeepers to approve or disapprove covering medical services -- say lying is unethical and unnecessary.

At an American Medical Association conference last year, Tufts University School of Medicine researcher Matthew Wynia polled 134 doctors about the pressure they felt to lie to Health Maintenance Organizations (HMOs) so patients would get proper medical care. In this unscientific sample, he found:

  • Some 70 percent of the doctors polled admitted exaggerating patients' symptoms to ensure HMOs wouldn't discharge them from hospitals prematurely.
  • Another 60 percent confessed they'd changed diagnoses on billing records to make sure treatments were covered.
  • Also, an audit at one hospital found HMOs routinely disallow 70 percent of emergency services, says Nancy Auer, president of the American College of Emergency Physicians, about the Seattle hospital where she practices.

However, a recent study found that initial denial rates for hospitalizations and surgical procedures have been running below 4 percent, with only about 1 percent ultimately denied after going through various appeals processes, says an official of the American Association of Health Plans. And, he points out, while most physicians reported no coverage denials, about 1 percent had 20 percent or more of their hospitalization requests denied.

Source: Editorial, "Doctors Fudge Truth to Avoid HMO Care Denials," and Donald A. Young (American Association of Health Plans), "Lying Unethical, Unnecessary," USA Today, November 11, 1998.


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