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Consider where insurance money, medicine meet

Article-Consider where insurance money, medicine meet

Dr. Levine
Fraud, particularly insurance fraud, can take many forms and come in many gradations. Perhaps one of the worst cases reported involved accusations against California surgeon William W. Hampton, M.D., and Mamdouh S. Bahna, M.D. In October 2005, they were accused of committing insurance fraud by luring people with private health insurance who were also willing to have unnecessary surgeries. Allegedly, they paid patients cash or gave them discounts on procedures then pocketed whatever the insurance companies paid out. Drs. Hampton and Bahna pled innocent to the charges.

While this case, describing not only fraudulent, but unethical conduct, is extreme, cosmetic surgeons describe a certain pressure they feel to commit a more subtle form of "creative billing" for patients involving coding cosmetic procedures as medically necessary in order to get insurance companies to pay for the treatment, whether in part or in full.

One of the most common types of health insurance fraud as listed by the Blue Cross and Blue Shield Association is the misrepresentation of what treatment was provided, the condition of the patient, or the diagnosis. And while it's not possible to determine an exact figure (though bills are being introduced in many states to step up investigation capabilities), some authorities claim that insurance fraud costs $100 billion annually.

Dr. Carraway
Norman Levine, M.D., professor of dermatology, University of Arizona, Section of Dermatology, Tucson, says that it is not uncommon for patients to ask plastic surgeons to code cosmetic procedures as medically necessary.

"I recently heard a story about a 19-year-old (woman) who asked to have the laser hair removal on her legs be coded as a medical procedure because she got irritated when she shaved," he recalls. "We're supposed to be in the patient's corner, but it's our responsibility to act ethically."

Many doctors who do miscode procedures do so in order to please their patients, Dr. Levine says. Or, he adds, some people also see insurance companies as big, greedy entities that aren't affected by what they see as little white lies.

And, Dr. Levine says, "When insurance companies pay for it, everyone else pays for it. Higher bills result in higher premiums. I always ask patients (who ask to code the procedure) whether they would still get a cosmetic procedure done if they had to pay for it themselves. Often, the answer is no."

Unified stance needed

Dr. Wheeland
While insurance companies and the United States government alike are coming up with new ways to crack down on insurance fraud, Dr. Levine believes a unified stance by doctors is what will truly have an impact. He cites the once-common professional courtesy wherein doctors did not charge other doctors for treatment, and which carried financial and ethical implications. Shifting away from that practice, he notes, was not easy and many doctors were angry at first.

"But once doctors banded together and the new rules were established, there formed a culture of understanding (of why such practices are not for the good of the whole), doctors began to play it straight," he says. "That is why it's important that doctors band together on this issue so that patients and other doctors learn not to take advantage of the system."

He adds that the ultimate positive outcome by refusing to miscode procedures is that physicians take the moral high ground — that of taking care of society's needs.

New technologies

James Carraway, M.D., professor and chairman, Division of Plastic Surgery, East Virginia Medical School, Norfolk, Va., agrees.

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