October 27, 1997

Physicians Who Report Health Insurance Fraud and Their Practice Type: Health Maintenance Organization vs Fee-for-Service

Author Affiliations

Elmhurst, NY

Arch Intern Med. 1997;157(19):2270. doi:10.1001/archinte.1997.00440400122014

Farber et al1 found that physicians practicing in health maintenance organization (HMO) settings compared with those in fee-for-service settings were more likely to suggest reporting patients committing health insurance fraud in the scenarios presented in their questionnaire. In their discussion, the authors opine, Physicians who practice in staff-model HMOs... may feel more allegiance to third-party payers than physicians working primarily in a fee-for-service practice. In addition, physicians in an HMO setting may have a greater financial incentative to report insurance fraud, because their financial well-being is more directly related to the financial health of the third-party payers.

An alternative hypothesis explaining the difference is that fee-for-service physicians, in reporting patients committing insurance fraud, may directly affect the likelihood that their fees will be paid. That is, fee-forservice physicians may find that their decision is more directly related the financial health of their own practice, whereas HMO physicians are watching

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