Context
Health plan utilization review rules are intended to enforce insurance
contracts and can alter and constrain the services that physicians provide
to their patients. Physicians can manipulate these rules, but how often they
do so is unknown.Objective
To determine the frequency with which physicians manipulate reimbursement
rules to obtain coverage for services they perceive as necessary, and the
physician attitudes and personal and practice characteristics associated with
these manipulations.Design, Setting, and Participants
A random national sample of 1124 practicing physicians was surveyed
by mail in 1998; the response rate was 64% (n = 720).Main Outcome Measure
Use of 3 different tactics "sometimes" or more often in the last year:
(1) exaggerating the severity of patients' conditions; (2) changing patients'
billing diagnoses; and/or (3) reporting signs or symptoms that patients did
not have to help the patients secure coverage for needed care.Results
Thirty-nine percent of physicians reported using at least 1 tactic "sometimes"
or more often in the last year. In multivariate models comparing these physicians
with physicians who "never" or "rarely" used any of these tactics, physicians
using these tactics were more likely to (1) believe that "gaming the system"
is necessary to provide high-quality care today (odds ratio [OR], 3.67; 95%
confidence interval [CI], 2.54-5.29); (2) have received requests from patients
to deceive insurers (OR, 2.44; 95% CI, 1.72-3.45); (3) feel pressed for time
during patient visits (OR, 1.69; 95% CI, 1.21-2.37); and (4) have more than
25% of their patients covered by Medicaid (OR, 1.60; 95% CI, 1.08-2.38). Notably,
greater worry about prosecution for fraud did not affect physicians' use of
these tactics (P = .34). Of those reporting using
these tactics, 54% reported doing so more often now than 5 years ago.Conclusions
A sizable minority of physicians report manipulating reimbursement rules
so patients can receive care that physicians perceive is necessary. Unless
novel strategies are developed to address this, greater utilization restrictions
in the health care system are likely to increase physicians' use of such manipulative
"covert advocacy" tactics.
Figures in this Article
Physicians' decisions about what services to offer their patients affect
almost 80% of all health care expenditures and have an enormous influence
on health care quality.1- 2 To
control cost and quality and ensure adherence to their contracts, health care
delivery organizations and payers frequently review physician recommendations
and pay for services (eg, diagnostic tests, drugs, or hospitalization for
treatment) only in predefined circumstances. This utilization review may occur
prospectively, in the form of preauthorization; concurrently, requiring immediate
approval over the telephone; or retrospectively, with payment decisions being
made after services have been delivered. Specific utilization review criteria
are rarely spelled out in advance; what physicians agree to when they sign
health plan contracts varies greatly and may both alter and constrain physicians'
decisions regarding their patients' use of services.
Although utilization review may be intended to improve quality and save
money, many physicians and patients dislike conforming to its rules. Utilization
review is often viewed as overly time consuming, a hassle, and an undue questioning
of professional authority.3- 4
Appealing adverse coverage decisions may seem inconvenient, unproductive,
or even risky for physicians. In some cases, physicians may feel trapped between
professional obligations to advocate for their patients and conflicting contractual
obligations to follow coverage rules. Furthermore, it has been suggested that
some insurers are "gaming" patients and physicians—tricking them into
paying for covered services by routinely denying coverage but then approving
services that are subsequently appealed, knowing that time and other constraints
will prevent some appeals.4- 6
To retaliate, physicians may be tempted to turn the tables.
Physicians could manipulate reimbursement rules to help their patients
obtain coverage for care that the physicians perceive to be necessary, for
example, through ambiguous documentation or by exaggerating the severity of
patients' conditions.7- 9
This sort of deception of third-party payers has been called "gaming the system"
for patients5 and it is not a new idea, nor
is it limited to managed care. Fee-for-service payment often provides a greater
financial incentive for physicians to manipulate reimbursement rules since
they directly profit from increased services. Yet recent data suggest that
physicians in regions with higher managed care penetration are more likely
to condone manipulating reimbursement rules.9
Some may believe that it is necessary to manipulate reimbursement rules in
the course of patient advocacy today—even in the face of well-publicized
crackdowns on fraud and abuse.10- 12
These physicians may see manipulation of reimbursement rules as an indirect,
or covert, form of patient advocacy and even a professional obligation.
Previous studies have posed hypothetical coverage dilemmas to physicians
and offered deception of insurers as potential solutions.9,13- 14
These studies demonstrate that many physicians believe there are scenarios
in which manipulating reimbursement rules would be justifiable in theory.
Anecdotes suggest that using such tactics is not merely hypothetical but occurs
in practice.15 This study sought to determine
how many physicians are manipulating reimbursement rules to get coverage for
their patients' needed care, and what factors might affect how frequently
physicians circumvent utilization review in practice.