AMA: Many physicians deceive third-party payers

Does anyone else hear that alarm sounding? Researchers from the American Medical Association (AMA) are reporting that "physician deception of third-party payers is prevalent and may be rising," based on their recent survey of physicians.

In addition, the investigators report that "also prevalent and rising are physicians informing patients that [the patients] should pay for uncovered services out-of-pocket and physicians not telling patients about useful but uncovered services." AMA researcher Deborah Cummins, MD, and colleagues at the AMA reported their findings at a recent meeting of the organization.

They collected data in a 1998 national survey of 724 randomly selected physicians involved in patient care. They were asked how often they employed one of three defined "deceptive strategies" to obtain coverage of services for patients:

• exaggeration of the severity of the patient’s condition in order to avoid early discharge from the hospital;

• changing the billing diagnosis to help secure services;

• reporting symptoms that the patient did not have in order to obtain coverage and treatments.

Cummins and her colleagues also asked the participants about how often they asked patients to pay out-of-pocket for services and how often they refrained from offering useful services to patients because those services were not covered by the patients’ plans.

Thirty-nine percent reported that they had "sometimes," "often," or "very often" used one of the three forms of deception. Only 28% of physicians said they had "never" used any of those forms of deception within the past year. Cummins says there was no correlation between the physician’s fear of fraud prosecution, or lack thereof, and the likelihood of participating in the three deceptive activities.

The doctors’ actions were not always behind the patients’ backs. Thirty-seven percent of physicians reported that their patients asked them to deceive third-party payers. Those physicians were most likely to have used deceptive strategies. Also, 31% of physicians had "sometimes" or more often refrained from offering useful or needed services to patients because of a lack of coverage by the patient’s plan. The physicians who admitted using any deceptive strategies were less satisfied with the practice of medicine, less financially secure themselves, less likely to try to talk patients out of unnecessary procedures, more dissatisfied with the amount of time available during patient visits, and more likely to voice annoyance at intrusion of insurance companies on their practice.

The survey detected a note of dissatisfaction about the goal of all the money-saving efforts in managed care today. Fifty-five percent of physicians said they would be "more aggressive in cost-control efforts if they knew that money saved would go towards serving more needy patients," Cummins reports.