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Is honesty still the best policy?
J Oral
Maxiliofac 1999
Surg
57: 1393,
Is Honestv
d
Still the Best Policy? ated diagnosis can ultimately come back to harm them at some future time when another doctor reviewing the record fails to recognize that the patient never had that particular problem. An inappropriate diagnosis can also lead to a future loss of insurance coverage if the patient changes health insurance plans and has a preexisting condition exclusion in the policy. Another negative consequence of an exaggerated diagnosis can occur when the doctor makes the change without informing the patient and the patient subsequently learns of the “condition” and believes that this is an accurate diagnosis. A case is cited in which a physician recorded a diagnosis of a brain tumor to ensure that the patient, who had lung cancer, would receive coverage for a scan to rule out metastasis to the brain. The patient subsequently received an insurance statement that listed the diagnosis as a brain tumor and committed suicide. Although exaggerating or altering a diagnosis to obtain insurance coverage for a patient may be done independently by some doctors in an attempt to fulfill their role as a patient advocate, at other times it is done at the request of the patient. The AMA survey showed that 37% of the physicians had patients who requested that they deceive a third-party payer. In the latter circumstance, one may feel uncomfortable about saying no to the patient and concerned that such a response might interfere with the doctor-patient relationship. However, while complying with the patient’s request may help to resolve this issue, there is also the possibility that subsequently patients may wonder about the doctor’s honesty and whether those who lie for them may also lie to them. Moreover, one patient may tell another, and this could result in an even more untenable position. There is no question that we have an obligation to help our patients as much as possible by appealing a denied service that we believe is in their best interest. However, our advocacy should always remain within the appropriate legal and ethical boundaries. Even if a claim is denied, sufficient complaints about the lack of coverage for medically necessary procedures could ultimately result in the insurance carriers changing their stance, and this is even more likely if they know that the doctors are being honest. In the end, no matter how we feel about managed care, honesty is still the best policy. Lying is not the way to fix the system!
When one establishes a doctor-patient relationship, they assume certain obligations. First and foremost, is the doctor’s obligation to provide the best possible care for the patient. Inherent in this concept is the need to inform the patient of all of the available treatment options, regardless of whether they include procedures that are not reimbursable by the insurance carrier. There is also an obligation to provide all of the information that is necessary for the patient to make an informed decision about treatment selection and to answer whatever questions they may ask. Finally, there is the obligation to act as an advocate for patients and to see that they receive the treatment that they need. The latter is perhaps the most difficult role to fulfill in the current managed care environment. What do you do when patients need a certain procedure that the insurance carrier refuses to cover and they pressure you to intercede on their behalf? It is one thing to be a patient advocate; it is another thing to be dishonest in this effort. A recent article in the American Medical News (42:1, 1999) entitled “Is it OK to Lie to Help Your Patient” addresses the ethical and legal problems associated the use of deception to secure insurance coverage for patients. In a survey of more than 400 physicians conducted by the American Medical Association’s (AMA) Institute for Ethics they found that 39% reported that during the past year they had sometimes, often, or very often used some deception to help patients obtain coverage for needed services. Twenty-eight percent exaggerated the severity of the patient’s condition to help them avoid early discharge from the hospital, 23% changed a billing diagnosis, and 9% reported symptoms that the patient actually did not have to help them secure coverage for needed treatments. Similar results were found in a recent Kaiser Family Foundation/Harvard University School of Public Health survey, which showed that 48% of the physicians polled admitted that in the past 2 years they had exaggerated the severity of the patient’s condition to obtain coverage for what they believed to be medically necessary. In addition to the obvious legal implications of such actions, because the medical record is a legal document, there is also the question of ethics. Although it is perhaps easier to justify engaging in falsification when one feels that the end result is beneficial to the patient, it is still ethically wrong. Moreover, such acts actually may not always be beneficial to the patient. In the first place, changing patients’ records to reflect an incorrect or exagger-
DANIEL
1393
M.
LASKIN
Maxiliofac 1999
Surg
57: 1393,
Is Honestv
d
Still the Best Policy? ated diagnosis can ultimately come back to harm them at some future time when another doctor reviewing the record fails to recognize that the patient never had that particular problem. An inappropriate diagnosis can also lead to a future loss of insurance coverage if the patient changes health insurance plans and has a preexisting condition exclusion in the policy. Another negative consequence of an exaggerated diagnosis can occur when the doctor makes the change without informing the patient and the patient subsequently learns of the “condition” and believes that this is an accurate diagnosis. A case is cited in which a physician recorded a diagnosis of a brain tumor to ensure that the patient, who had lung cancer, would receive coverage for a scan to rule out metastasis to the brain. The patient subsequently received an insurance statement that listed the diagnosis as a brain tumor and committed suicide. Although exaggerating or altering a diagnosis to obtain insurance coverage for a patient may be done independently by some doctors in an attempt to fulfill their role as a patient advocate, at other times it is done at the request of the patient. The AMA survey showed that 37% of the physicians had patients who requested that they deceive a third-party payer. In the latter circumstance, one may feel uncomfortable about saying no to the patient and concerned that such a response might interfere with the doctor-patient relationship. However, while complying with the patient’s request may help to resolve this issue, there is also the possibility that subsequently patients may wonder about the doctor’s honesty and whether those who lie for them may also lie to them. Moreover, one patient may tell another, and this could result in an even more untenable position. There is no question that we have an obligation to help our patients as much as possible by appealing a denied service that we believe is in their best interest. However, our advocacy should always remain within the appropriate legal and ethical boundaries. Even if a claim is denied, sufficient complaints about the lack of coverage for medically necessary procedures could ultimately result in the insurance carriers changing their stance, and this is even more likely if they know that the doctors are being honest. In the end, no matter how we feel about managed care, honesty is still the best policy. Lying is not the way to fix the system!
When one establishes a doctor-patient relationship, they assume certain obligations. First and foremost, is the doctor’s obligation to provide the best possible care for the patient. Inherent in this concept is the need to inform the patient of all of the available treatment options, regardless of whether they include procedures that are not reimbursable by the insurance carrier. There is also an obligation to provide all of the information that is necessary for the patient to make an informed decision about treatment selection and to answer whatever questions they may ask. Finally, there is the obligation to act as an advocate for patients and to see that they receive the treatment that they need. The latter is perhaps the most difficult role to fulfill in the current managed care environment. What do you do when patients need a certain procedure that the insurance carrier refuses to cover and they pressure you to intercede on their behalf? It is one thing to be a patient advocate; it is another thing to be dishonest in this effort. A recent article in the American Medical News (42:1, 1999) entitled “Is it OK to Lie to Help Your Patient” addresses the ethical and legal problems associated the use of deception to secure insurance coverage for patients. In a survey of more than 400 physicians conducted by the American Medical Association’s (AMA) Institute for Ethics they found that 39% reported that during the past year they had sometimes, often, or very often used some deception to help patients obtain coverage for needed services. Twenty-eight percent exaggerated the severity of the patient’s condition to help them avoid early discharge from the hospital, 23% changed a billing diagnosis, and 9% reported symptoms that the patient actually did not have to help them secure coverage for needed treatments. Similar results were found in a recent Kaiser Family Foundation/Harvard University School of Public Health survey, which showed that 48% of the physicians polled admitted that in the past 2 years they had exaggerated the severity of the patient’s condition to obtain coverage for what they believed to be medically necessary. In addition to the obvious legal implications of such actions, because the medical record is a legal document, there is also the question of ethics. Although it is perhaps easier to justify engaging in falsification when one feels that the end result is beneficial to the patient, it is still ethically wrong. Moreover, such acts actually may not always be beneficial to the patient. In the first place, changing patients’ records to reflect an incorrect or exagger-
DANIEL
1393
M.
LASKIN