Hassle factor linked to misleading of insurers

OB/GYN News, Nov 15, 2001 by Norra MacReady

SAN DIEGO -- Would you ever consider lying to an insurer?

When researchers posed that question to 1,617 randomly selected American physicians, 77% said they would appeal a decision they disagreed with, while 12% said they would accept the company's decision to deny coverage, and 11% indicated they would deliberately mislead the insurer to obtain medically necessary services for a patient.

But the respondents' willingness to mislead an insurer increased as the "hassle factor" surrounding the appeal increased, Dr. Caleb Alexander said in a poster session at the annual meeting of the Society of General Internal Medicine.

Dr. Alexander and his colleagues at the University of Pennsylvania Health System presented each doctor with a hypothetical scenario in which an insurance company refused to pay for a medically important service. They varied the "hassle factor" by changing the time required to make an appeal and the likelihood of successfully appealing. They also varied the severity of the patient's condition from moderate low back pain to severe angina. The subjects were asked if the patient's physician should accept the insurance company's restriction, appeal the restriction, or misrepresent the facts to the insurance company in order to obtain coverage for the patient.

"We found that as the likelihood of a successful appeal decreased or the amount of time for the appeals process increased, doctors were increasingly likely to misrepresent the facts" for patients whom they perceived to have life-threatening conditions, Dr. Alexander said during an interview.

Doctors who were asked about the severe angina case, for example, were more likely to misrepresent the facts to the insurer rather than appeal as the appeals process became more cumbersome. When asked about a patient with moderate low back pain, physicians' decisions about how to respond to an insurance company restriction were not significantly affected by the hassle associated with the appeals process.

The odds ratio that a physician would lie due to a lengthy appeals process was 1.68; if the appeal was less likely to succeed, the ratio was 1.57, and if the condition was more severe, 2.19.

This study "confirms that a substantial minority of doctors are willing to misrepresent information to insurance companies to get medically necessary care for their patients," Dr. Alexander commented.