Laws, AMA offer limited guidance on patient fraud

Guidelines tend to support confidentiality

One of the difficulties in making decisions about patient fraud is that so few guidelines exist in this area, says Neil J. Farber, MD, an oncologist and lead author of a recent study on patient fraud.

Here are key points to know about what legal and ethical guidelines do exist in this area, Farber says:

Laws tend to support confidentiality, with certain exceptions. Most states to not require physicians to disclose felonies committed by patients, and physicians are protected by that understanding. Here are the key exceptions:

— Courts usually allow physicians to breach confidentiality when key societal interests are involved.

— Under strict guidelines of disclosure of information, physicians are allowed to communicate information to third-party payers who reimburse for treatment.

— Laws require physicians to report certain diseases that could harm others. For example, names of patients with epilepsy should be reported to state motor vehicle departments.

AMA’s ethics guides tend to support confidentiality, with some exceptions. Overall, AMA ethics guidelines urge confidentiality. The AMA makes these similar exceptions to maintaining confidentiality:

— in the case of infectious diseases;

— when laws require disclosure;

— when there is need to protect either "individual or public interest," although no guidelines exist for determining when individual or public interest outweigh confidentiality concerns.

Insurers are attempting to help physicians, says Sonya Albertson, program integrity officer for Minneapolis-based Blue Cross and Blue Shield of Minnesota. "We use a lot of advertisement vehicles — fraud hotlines, newsletters, seminars, bulletins. We also write case studies of examples we encounter so physicians can understand what patients might be doing."