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What Motivates Physicians to Manipulate Reimbursement Rules?

Rachel M. Werner, MD; G. Caleb Alexander, MD; Angela Fagerlin, PhD; Peter A. Ubel, MD

Arch Intern Med. 2002;162:1134-1139.

Background  Some physicians are willing to misrepresent clinical information to insurance companies to circumvent appeals processes. Whether characteristics of appeals processes affect the likelihood of misrepresentation is unknown. This study sought to determine the relationship between the likelihood of a successful appeal, appeals process length, and severity of the health condition and physicians' willingness to sanction deception.

Methods  A random sample of 1617 physicians was surveyed by mail to assess their willingness to accept an insurance company restriction, to appeal the restriction, or to misrepresent the facts to an insurance company to obtain coverage for a patient.

Results  Most respondents would appeal (77%) rather than accept (12%) or misrepresent (11%) regarding a restriction on medically necessary care. Physicians' decisions were related to the likelihood of a successful appeal (² = 7.56; P = .02), the appeals process length (² = 8.53; P = .01), and the severity of the medical condition (² = 71.10; P<.001). A small but significantly larger number of physicians chose to misrepresent the facts to an insurer as the appeals process became more cumbersome. Among physicians asked about severe angina, their decisions were particularly affected by the hassle associated with appealing, being more likely to choose to misrepresent the facts to the insurer than to appeal as the hassle increased.

Conclusions  Physicians are more willing to sanction deception when the appeals process is longer, the likelihood of a successful appeal is lower, and the health condition is more severe. Changes in the difficulty of appeals processes may ease the tensions physicians face regarding patient advocacy and honesty.

From the Department of Internal Medicine, University of Pennsylvania, Philadelphia (Drs Werner and Alexander); the Veterans Affairs Medical Center, Ann Arbor, Mich (Drs Fagerlin and Ubel); the Division of General Internal Medicine, University of Michigan, Ann Arbor (Drs Fagerlin and Ubel); and the Program for Improving Health Care Decisions, Ann Arbor (Drs Fagerlin and Ubel). Dr Werner is now with the Division of General Internal Medicine, the University of Pennsylvania. Dr Alexander is now a Robert Wood Johnson Clinical Scholar at the University of Chicago, Chicago, Ill.

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