Is It Considered Insurance Fraud for a Clinician to Try to Save a Patient Money on RX

[NRSKarenRN, BSN, RN]

Legal/Professional Issues for Advanced Practice Nurses Ask The Expert

Posted 06/19/2003

Is It Considered Insurance Fraud for a Clinician to Try to Save a Patient Money on Pr

from Medscape Nurses

Question

Is it insurance fraud to save a patient money on prescriptions by treating, for example, "androgenic alopecia" with a prescription for finasteride (Proscar) -- a treatment for benign prostatic hypertrophy -- instead of the more expensive finasteride (Propecia) used to treat male pattern hair loss?

Response

from Carolyn Buppert, CRNP, JD, 06/19/2003

Yes, it is fraud, unless the patient has benign prostatic hypertrophy (BPH) and is balding. Fraud is defined as: "an intentional deception or misrepresentation which the individual knows to be false or does not believe to be true, and the individual is aware that the deception could result in some unauthorized benefit to him/herself or some other person."[1]

Full response(Free registration required)

http://www.medscape.com/viewarticle/456510?mpid=15178

[canoehead, BSN, RN]

Why couldn't they just order it by the generic name?

[renerian, BSN, RN]

Dr's prescribe all kinds of medications for patients if the medication has a side effect to help the person. Ie) my stepdaughter has an eating disorder. One of the side effects is increased appetite for the med they put her on. It helped her gain weight.

renerian

[canoehead, BSN, RN]

True, I don't think off label use is insurance fraud. The drug companies might not like prescribing the less expensive brand name, but the insurance companies are probably all for it. Why would they prosecute?

[memphispanda, RN]

I personally think it's fraud for the drug companies to market the same ingredient under 2 different names, implying that they are different products in order to have higher products.

[canoehead, BSN, RN]

Agree.