PROFESSIONAL ISSUES

Would you fib for your patient?

Your patient needs a procedure the insurer won't cover. Now what?

By Andis Robeznieks, AMNews staff. June 13, 2005.

Your patient needs bypass surgery, but her insurance company says to wait and see if her condition worsens or else they won't pay for the care. Do you fudge and say her condition is a bit more dire than it really is, performing the surgery with the peace of mind that the insurer will cover the cost? Or do you play by the insurer's rules?

About one in 10 physicians said they approve of gaming the system to get patients the treatment they believe is necessary, according to a study, "Lying to Insurance Companies: The Desire to Deceive Among Physicians and the Public," published in the December 2004 American Journal of Bioethics.

Patients are even more comfortable with the idea and might be asking their doctors to embellish symptoms on their behalf.

About one in four people surveyed from the general public approve of a doctor misrepresenting facts to an insurance company under certain circumstances, according to the study author Rachel M. Werner, MD, PhD, and her colleagues.

In the past, experts have described bending the rules for a patient's benefit as "uncommon but far from rare" among physicians, and this most recent study continues to support that characterization. Yet some fear that the practice will grow as patients' insurance policies become less comprehensive and doctors have less time to navigate complicated appeals processes.

The American Medical Association and other medical societies oppose deception regardless of intent. But physicians need to determine how they'll handle patients asking them to fudge the facts because -- as Dr. Werner's research showed -- patients might feel that gaming the system is justified.

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