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

Ira L. Salom, MD
Arch Intern Med. 1997;157(19):2270. doi:10.1001/archinte.1997.00440400122014.
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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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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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