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March 10, 1997

Confidentiality and Health Insurance Fraud

Author Affiliations

From the Section of General Internal Medicine, Veterans Affairs Medical Center, Allegheny University of the Health Sciences (Dr Farber), Section of Hematology/ Oncology (Dr Berger) and Section of General Internal Medicine (Dr Ubel), Veterans Affairs Medical Center, University of Pennsylvania School of Medicine, Department of Management and Information Systems, St Joseph's University (Drs Davis and Boyer), Management Department, Drexel University (Dr Weiner) Philadelphia, Pa.

Arch Intern Med. 1997;157(5):501-504. doi:10.1001/archinte.1997.00440260035007

Background:  Health insurance fraud committed by patients may be an increasing problem given the number of underinsured and uninsured people in the United States. Physicians recognizing acts of health insurance fraud perpetrated by patients face an ethical dilemma: should they disclose the incident to the insurance company, or protect patient confidentiality?

Objective:  To explore physicians' attitudes toward the reporting of patient-initiated health insurance fraud.

Methods:  Three hundred seven physician members of the American College of Physicians returned a mailed questionnaire that presented 6 case vignettes (3 variables) of patients who used a relative's insurance to obtain health care in the past. For each vignette, respondents were asked whether the treating physician should report insurance fraud to the health insurance carrier.

Results:  Sixty-three respondents (20.7%) indicated that physicians should report all the patients presented in the vignettes, while 45 (14.8%) indicated none should be reported; the rest indicated that the decisions to report should be based on the characteristics presented, with acute vs terminal illness (P<.001), history of fraud (P<.001), and wealth of the patient (P<.001) all causing physicians to be more likely to report the patient to the health insurance carrier. Multivariate analysis demonstrated that type of practice (P=.04) and respondents' experiences with insurance fraud (P=.03) had significant effects on the willingness to report patients.

Conclusions:  Physicians are divided about whether to report patients who have committed insurance fraud. Their decisions to report insurance fraud are influenced by their attitudes and demographic features, as well as by patient factors.Arch Intern Med. 1997;157:501-504