Question

Health care insurers often deny insurance reimbursement for certain DSM classifications that are common among clients served by psychologists. Discuss the ethical issues related to upcoding a disorder in order to obtain reimbursement for services.

Answer 1

Health care insurers usually deny insurance reimbursements for DSM(Diagnostic and Statistical Manual of Mental disorders). So the patients with diagnosis not covered by the insurance policy may not have funds to pay out of the pocket cost. Due to this some psychologists are tempted to upcode or overdiagnose a certain disorder to establish a diagnosis meeting the insurer's benefits criteria. This is unethical and illegal practice which is well presented as an insurance fraud well termed as violation of standard 4.0 Fees and financial arrangement. It does not comply with Principle C: Integrity under which psychologists do not engage with fraud and intentional misrepresentation of fact.

It also violates standard 3.06 Conflict of interest, which allows personal and financial gains overpower objectives of psychology.Those psychologists suspected under this can be investigated and prosecuted under False claims Amendments act 1986, which allows clients to bring cases against practitioners in government's behalf. Those who are found guilty are forced to give away their license and practice, sometimes they are asked to pay monetary penalties and spend some time in jail. Their career is shattered.