Fabricate Findings for a Payable Diagnosis?

February 6, 2012
Eric Postal, MD

In our bizarre world of getting paid not for what we do but rather why we did it, we often find ourselves holding the bag when a referrer ordered a study that the insurer decided was “inappropriate.”

Ever invented a diagnosis?

I’m not talking about dictating that a CT shows “grade-3 collywobbles.” Rather, I refer to the instance of reporting something genuinely found in reputable medical texts - just not, strictly speaking, on the images of the case in front of you.

Unthinkable, surely. None of us can imagine someone with an axe to grind, say, concocting a diagnostic “miss” during peer review in an attempt to zing a disfavored colleague. Or the owner of an acromegalic ego feeding a not-necessarily-conscious need to be the smartest guy in the room, seeing an abnormality that he claims others have missed. “A very subtle finding,” he might charitably comment, “Totally understandable that you didn’t see it.” At which point others in the room can either A) risk looking dumb by admitting that they still see nothing abnormal, or B) appreciatively discuss the Emperor’s New Diagnosis.

Perhaps another (entirely hypothetical - no accusations here), more forgivable temptation to fabricate findings: An awareness that one might not get reimbursed for reading the study, otherwise. In our bizarre world of getting paid not for what we do but rather why we did it, we often find ourselves holding the bag when a referrer ordered a study that the insurer (or government) decided was “inappropriate.”

Of course, we did the study without waiting to see whether it would meet with approval…and now, payment will only be forthcoming if we can find a diagnosis which is payable for the study. Call it normal, and you eat the cost (but keep the liability). But if you can find some subtle ailment that may or may not be there, well, now you’re in business!

My days in clinical psychology are long behind me, but I suspect that even the most ethical individual would be at least subconsciously influenced by such factors.

A little closer to home for most of us: How satisfying is it, having received an imaging study, to come up with no diagnosis whatsoever? The patient’s got pain in the right lower quadrant, Answer Man! Whaddaya mean, there’s nothing abnormal there?

It’s even tougher when the clinician says that it’s a “classic presentation,” or a “very acute abdomen.” Gosh, really? Hmm…well, the bowel there is really not distended, but I guess it could possibly be a little thickened. Better err on the side of overcalling.

I had occasion to ask some clinicians (mostly ER folks) recently about their take on potentially-overcalled or equivocal cases. Stuff that wouldn’t lead to surgery or anything major like that, but verbiage that did give them a potential diagnosis. I thought for sure I’d get an earful about how unhelpful it was to hand them these red herrings that might distract from their patients’ real issues. Instead, the sentiment was surprisingly positive: They liked having an answer, however flimsy, and a reason to discharge the patient with PO meds and an appointment for follow-up with their primary docs. The patients liked having a name for their pain, too.

I have to admit that this goes against my grain. My feeling is that it’s either on the images or it’s not, and we undermine our credibility if we blur that line. Like Dragnet’s Joe Friday, I’m interested in “Just the facts, ma’am.” Which, incidentally, he never said. See how made-up stuff takes on a life of its own?