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Chiropractic Research Review

Manipulation of Reimbursement Rules to Maximize Patient Care

Health care delivery organizations and payers frequently review clinical recommendations and pay for services only in predefined circumstances. Although utilization review may be intended to improve quality and save money, many physicians and patients dislike conforming to the rules, and it has been suggested that physicians may feel trapped between professional obligations toward their patients and conflicting contractual obligations to adhere to established coverage rules.

Results from previous studies, in which investigators posed hypothetical coverage dilemmas to physicians and offered deception of insurers as potential solutions, provide evidence that many physicians believe that manipulating reimbursement rules is at least theoretically justifiable.

The authors of the current study investigated this further with a survey mailed in 1998, to a random sample of 1,350 U.S. physicians. Results from the 720 physician responses are presented as follows:

* Thirty-nine percent of physicians reported using at least one tactic "sometimes" in the last year.

* Fifty-four percent of these physicians reported employing such tactics more often now than five years ago.

* Physicians using these tactics were more likely to believe that "gaming the system" is necessary to provide high quality care; have received patient requests to deceive insurers; feel pressed for time during patient visits; and have more than 25% of patients covered by Medicaid.

* Concern about prosecution for fraud did not affect physicians' use of these tactics.

Conclusion: The authors note that "health plans in which the use of these tactics is common should carefully review their rules and procedures, and work with physicians to reduce the perceived need for covert advocacy."

Wynia MK, Cummins DS, VanGeest JB, et al. Physician manipulation of reimbursement rules for patients. Journal of the American Medical Association, April 12, 2000:283(14), pp1858-65.

Chiropractic Research Review

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