Law and Ethics for Medical Careers 3rd Edition

1
Law and Ethics for Medical Careers 3rd Edition

• Insurance Fraud (1, 3)
• Coding and Reimbursement (1, 3,11)

2
The Case

• A Boston physician has a patient who has
  presented with changes in her fibrocystic breast
  condition. The patients insurance covers some
  examinations for this condition, but the patient
  fears an early-stage cancer would be easy to miss
  if she were examined at the frequency allowed by
  her insurer.

3
The Case, continued

• The patient states she cannot afford to pay out
  of pocket for the extra examinations that the
  physician agrees are desirable.
• The physician successfully got the insurer to pay
  for the most recent visit by coding it as an
  evaluation for breast mass rather than as a
  routine monitoring.

4
What Do You Think?

• The physician now wonders if this was a correct
  way to handle this situation and if it is wise to
  continue this practice.
• Do you think the physician handled the situation
  correctly? Why or why not?
• What recommendations would you give this
  physician?

5
Legal Issues

• In general, physicians should avoid chronic
  upcoding.
• A physician who knowingly states an incorrect
  diagnosis or billing code on an insurance form to
  obtain an unauthorized level or kind of
  reimbursement commits fraud.

6
Legal Issues, continued

• Major initiatives against fraud are under way
  from both federal and private health plans.

What penalties can be imposed on physicians found
guilty of fraudulent billing?
7
Legal Issues, continued

• Penalties include

• Loss of participation in insurance plans

• Fines

• Civil monetary penalties

• Imprisonment

8
Legal Issues, continued

• There may also be other negative outcomes of
  miscoding.
• In a malpractice suit, a physicians dishonesty
  in coding can undermine his credibility. This
  can occur even if the upcoding does not directly
  relate to the claim being litigated.

9
Ethical Issues

• Deliberate miscoding is dishonest and potentially
  harmful in several ways.
• Mistrust between physicians and health plans
• Mistrust between physicians and patients
• Harm to patients

10
Ethical Issues, continued

• Mistrust between physicians and health plans
  fuels a mutual gamesmanship that ultimately makes
  it more difficult, not easier, to secure the care
  a patient needs.

11
Ethical Issues, continued

• Patients may develop the fear that a physician
  who would openly lie for a patient might also
  sometimes lie to them.

12
Ethical Issues, continued

• Insurance dishonesty can also harm patients, as
  in the following case of Stafford v. Neurological
  Medicine, Inc.

13
Stafford v. Neurological Medicine, Inc.

• Physicians performed a CT scan prior to
  chemotherapy to determine if a patients lung
  cancer had metastasized to her brain. Believing
  the insurance company would not pay for a
  screening CT scan, the physician entered a
  diagnosis of brain tumor on the claim form.

14
Stafford v. Neurological Medicine, Inc.

• The patient was told the exam was negative, but
  when she received a statement from her insurance
  company explaining the benefits paid, she saw
  brain tumor under diagnosis and became
  acutely distressed.

The patient committed suicide.
15
What Should a Physician Do?

• Chronic upcoding is unwise, unethical and
  illegal.
• What options do physicians have?

16
What the Expert Says

• Linda Emanual, MD, PhD, director of the AMA
  Ethics Institute suggests further investigation,
  combined with some creative problem-solving.
• She outlines three areas for problem-solving in
  this case...

17
What the Expert Says, continued

• First,
• Establish a reasonable frequency for screening
  for this patient.
• If anxiety is what prompts the patient to request
  more frequent visits, then more education and
  reassurance may be in order. This could prevent
  excessive screening.

18
What the Expert Says, continued

• Second,
• Determine if there actually is a reimbursement
  problem.
• Dont assume you must upcode to receive payment.
  Contact the insurer and talk to someone who knows
  the reimbursement system. More documentation may
  be required, but there may be reimbursement.

19
What the Expert Says, continued

• Third,
• Find out what the patient means by cant
  afford.
• Today patients are accustomed to first-dollar
  coverage and may believe they should never have
  to pay for medical care.

20
What the Expert Says, continued

• If a physicians charges are comparable to other
  costs of everyday living, then a decision not to
  purchase extra medical services may be just that
  -- a spending decision.

21
What the Expert Says, continued

• If this is the case, the patient should be
  informed by the physician why the exams are
  important and the consequences of not having the
  exams.
• Payment plans may then be offered.

22
What the Expert Says, continued

• When costs present a true obstacle,
• A physician may discount her own fees.
• A physician may wish to negotiate discounted fees
  from other required services, such as mammography.

23
Summary

• Physicians must recognize dilemmas such as this
  cannot be avoided. Patients needs are diverse
  and payers must limit what they will cover.
• The challenge is not to bypass the problem, but
  to live with it in morally credible ways.
• Ethics Forum, American Medical News, February 23,
  1998.