Lying to insurance to help patients?

[anbuitachi]

So I can across this question and I wasn't sure what the "correct" way to answer it is. Everyone knows that some doctors lie to insurance companies to help patients with no money or a insurance that doesn't cover the problem. For example a patient comes in with a mental disorder but the person's insurance doesn't cover it and the patient can't afford to pay herself. The doctor lies and reports it as a sleep disorder to the insurance which is covered to help the patient.

If asked during an interview if you would do something like this, what would you say? In one aspect i believe a doctors priority is to help the patient but on t he other hand, this isn't legal...

---

Members don't see this ad.

 

[WorldChanger36]

It is super illegal and it is wise to stay on the legal side of interview questions. I doubt it will come up but if it does state that you would not do anything illegal but you would aggressively advocate for your patient by waving your fees, consulting with other docs that will do the same, battling with the insurance company to get them to cover it, working out fair payment plans with the patient and try to get as much free access as possible for them by looking for clinics or acdemic projects that could help.

In other words stay legal but fight for your patient.

 

[Musclemass]

The circumstances when not telling the truth is acceptable are very, very few; this is not one of them.

 

[Lindlar]

It is super illegal and it is wise to stay on the legal side of interview questions. I doubt it will come up but if it does state that you would not do anything illegal but you would aggressively advocate for your patient by waving your fees, consulting with other docs that will do the same, battling with the insurance company to get them to cover it, working out fair payment plans with the patient and try to get as much free access as possible for them by looking for clinics or acdemic projects that could help.

In other words stay legal but fight for your patient.

I definitely think this is the best answer.

 

[gettheleadout]

It's better to stay on the legal side of things in general, not just for interview answers. While doing something illegal may enable you to help a particular patient more, if you lose your license you're prevented from helping any other patients. Think about it.

 

[apumic]

Lying to insurance is FRAUD. This is a very big "no-no" in medicine. Definitely advocate for your patient, but giving a false dx can come back to haunt you.

 

[anbuitachi]

thanks guys. that makes sense

 

[MilkmanAl]

Lying to insurance is FRAUD. This is a very big "no-no" in medicine. Definitely advocate for your patient, but giving a false dx can come back to haunt you.

I'm pretty surprised it took this long for someone to say that. Also, if you lie to Medicaid/Medicare and get caught, it's a federal offense, and you're going to the pen. Totally worth sticking by your principles for, right?

 

[apumic]

I'm pretty surprised it took this long for someone to say that. Also, if you lie to Medicaid/Medicare and get caught, it's a federal offense, and you're going to the pen. Totally worth sticking by your principles for, right?

We have posters all over my hospital giving pts phone numbers to call if they suspect a physician or healthcare provider is committing fraud against Medicaid/Medicare. It's quite a big deal.... We actually had a physician get caught for this recently -- a very successful one -- and she committed suicide soon after finding out about the investigation.

 

[transfec]

Try not to lie at all...

 

[rHinO1]

So I can across this question and I wasn't sure what the "correct" way to answer it is. Everyone knows that some doctors lie to insurance companies to help patients with no money or a insurance that doesn't cover the problem. For example a patient comes in with a mental disorder but the person's insurance doesn't cover it and the patient can't afford to pay herself. The doctor lies and reports it as a sleep disorder to the insurance which is covered to help the patient.

If asked during an interview if you would do something like this, what would you say? In one aspect i believe a doctors priority is to help the patient but on t he other hand, this isn't legal...

You have been watching too much TV... don't lie or break the law.

 

[Big Dog]

The feds may not send a fraudulent doc to jail -- no room in the inn -- but they can ban you from accepting medicare/caid patients.

 

[ILikeDrugs]

One could say that lying to insurance companies costs the insurance companies money which they would then compensate for by jacking up their prices or refusing services to others. You'd be hurting those other patients. Don't answer in such a way that makes you look like a white knight that breaks the law. Real life Robin Hoods don't get the Disney treatment. 😉

 

[gettheleadout]

We have posters all over my hospital giving pts phone numbers to call if they suspect a physician or healthcare provider is committing fraud against Medicaid/Medicare. It's quite a big deal.... We actually had a physician get caught for this recently -- a very successful one -- and she committed suicide soon after finding out about the investigation.

Oh man...

 

[ILikeDrugs]

How is one able to tell if a physician is committing fraud? It's not like the typical patient knows when tests are unnecessary.

 

[apumic]

How is one able to tell if a physician is committing fraud? It's not like the typical patient knows when tests are unnecessary.

The posters we have list some suspicious activities pts might report. The fraud, btw, is moreso when a dx is untrue or something was charged but never actually done.

Additionally, other healthcare providers often do the reporting. Someone somewhere is going to be a whistleblower if it happens enough.

 

[group_theory]

It is super illegal and it is wise to stay on the legal side of interview questions. I doubt it will come up but if it does state that you would not do anything illegal but you would aggressively advocate for your patient by waving your fees, consulting with other docs that will do the same, battling with the insurance company to get them to cover it, working out fair payment plans with the patient and try to get as much free access as possible for them by looking for clinics or acdemic projects that could help.

In other words stay legal but fight for your patient.

Be careful with waiving your fees - even though you think you're doing the right thing for the patient. You may be violating federal and/or state laws as well as your contract with insurance (which can result in nonpayment as well as dropping you from their list of eligible providers) as well as potential investigations (by the feds and insurance companies) on whether you OWE payments made previously because you were commiting "fraud"

The following comes from the Minnesota Medical Association's flyer for physicians:

Physicians who receive payment through the Medicare or Medicaid programs and who routinely waive copayments and/or deductibles may be held in violation of federal and state anti-kickback statutes.
​

By routinely waiving copayments or deductibles, physicians could be providing an incentive for patients to choose their practice over another one at the expense of the Medicare and Medicaid systems and, thus, they would be in violation of the federal (and state) anti-kickback statutes. These types of violations can result in significant civil and criminal fines, imprisonment, and/or both.
​

The Office of the Inspector General stated that waiving Medicare and Medicaid copays or deductibles would not violate the Anti-kickback Statute if:

• The waiver is not offered as part of any advertisement or solicitation;
• The provider does not routinely waive coinsurance or deductibles; and
• The provider waives the coinsurance and deductibles after determining in good faith that the individual is in financial need or reasonable collection efforts have failed
​

The federal False Claims Act is a whistleblower law for employees, patients, and other individuals who suspect that false or fraudulent claims are being submitted to the government.

The U.S. Department of Health and Human Services Office of Inspector General has stated that a routine waiver of copayments and/or deductibles is equivalent to misstating charges to government programs including Medicare and Medicaid. These types of waivers would, therefore, constitute a violation of the federal False Claims Act.​

​

Persons found to be in violation of the federal False Claims Act will be assessed a civil penalty in addition to three times the amount of damages that the government sustains due to the submission of the fraudulent claim.

​

Under the Civil Monetary Penalties Law, a physician may not offer or transfer remuneration (including the waiver of coinsurance and deductible amounts, and the transfer of items or services for free or for other than fair market value​

​

​

​

) to a patient who is eligible for Medicare or Medicaid if the physician knows or should know that the waiver is likely to influence the patient to order or receive an item or service that will be paid by a government program.
​

A violation of this law can result in fines for each wrongful act.

There are some exceptions to this rule. Remuneration will not be found if the waiver meets the following three criteria:
1. It is not offered as part of an advertisement or solicitation;
2. The physician does not routinely (i.e. more than 50% of the time) waive co-insurance or deductible amounts; and
3. The waiver is granted after a good faith determination has been made that the patient has a financial need (or the physician is otherwise unable to collect coinsurance or deductible amounts after making reasonable collection efforts).

​

Physicians may routinely waive co-pays, deductibles and/or reduce fees for patients with privately-funded insurance provided that the insurance carrier knows of the waiver and/or reduction, and agrees to it. If the insurance carrier does not agree to it, a physician risks being accused of insurance fraud.

For example, assume that a physician’s usual and customary fee for a particular procedure is $100. If an insurance company agrees to pay 80 percent of that fee ($80.00) with the understanding that the remaining 20 percent will be paid by the patient, and then the physician routinely waives the patient’s portion of the bill, the insurance company could claim
that the physician was acting fraudulently because the usual and customary fee actually charged was 80% of the price originally quoted. This could result in the insurance company making the accusation that the it had been defrauded out of $16.00 and that it only owes 80% of the $80.00 it originally agreed to pay ($64.00).​

CAN PHYSICIANS REDUCE FEES FOR UNINSURED
PATIENTS?​

The answer to this question depends on what your contracts
with insurance carriers say. Some contracts contain clauses
that prohibit providers from charging the insurance company
more than what physicians charge other payers (including
uninsured patients). Providers are encouraged to review
their contracts for this type of provision prior to reducing​

their fees.

 

[LizzyM]

Keep in mind, too, that the patient may "benefit" from the "fraud". For example, if a treatment is not covered unless the patient also has X, then saying, incorrectly, that the patient has X in order to get the service paid for will "benefit" both physician and patient and there is no incentive by the patient to whistle blow.

 

[eablackwell]

I have a question for LizzyM and other people who really know the score about all this stuff.

Are there often clauses in a doctor's contract to keep them from volunteering at free clinics in their spare time or is this something that basically any doctor is legally allowed to do?

Thanks.

 

[juliedi]

Be careful with waiving your fees - even though you think you're doing the right thing for the patient. You may be violating federal and/or state laws as well as your contract with insurance (which can result in nonpayment as well as dropping you from their list of eligible providers) as well as potential investigations (by the feds and insurance companies) on whether you OWE payments made previously because you were commiting "fraud"

The following comes from the Minnesota Medical Association's flyer for physicians

Wow, I never knew this. Intense.