DEC 01, 2010
Question: A long-standing patient is concerned about her droopy eyelids, but she clearly does not meet insurance requirements to be considered “functional” for blepharoplasty surgery. She has asked me to exaggerate the necessity for the surgery in order to get her insurance to pay for the procedure. Is this ethical?
Answer: It is unethical to exaggerate your description of a patient’s condition in order to meet an insurance company’s documentation requirements for a particular cosmetic procedure. There is considerable legal risk for the physician who “miscodes” or misleads via documentation. In addition, there are significant medicolegal risks in the event of an untoward outcome. Rule 9 of the Academy Code of Ethics states, “An ophthalmologist must not misrepresent the service that is performed or the charges made for that service.”
With respect to the patient’s specific request, in most cases there is a relatively straightforward way to resolve this dilemma without upsetting the patient by refusal. Because most insurance carriers will only pay for blepharoplasty surgery in the case of documented functional disability, the carrier will require visual field tests and external photos of the patient to substantiate the authorization. Then the insurance carrier will either authorize the surgery or not based on its review of this objective data and not on the opinion of the surgeon. Once informed of this fact, the reasonable patient will understand your justification for declining her request. In the absence of that understanding, you may wish to suggest the patient obtain a second opinion or, in the case of a persistent patient, end the physician- patient relationship and offer referral to other practitioners.
For more information or to submit a question for this column, contact the Ethics Committee staff at ethics@aao.org.