Is this insurance fraud? Unethical or illegal?

[threecrazykids]

I posted this on the community board, but now I'm wondering if/how this can affect insurance premiums. Not sure it even does...but I would think in some round about way it might...

I have a neighbor whom I would consider myself "friendly" with. By no means are we BFF but we do talk frequently. I like her, but she's the type of person I keep at arms length because for some reason she always feels the need to try to make me believe all of her friends are so rich and successful etc.

Anyway, her and another neighbor of ours (who DOESN'T always do the "my friends are so rich game) were friends before they moved into our cul-de-sac. We were all 3 talking in our yards the other day about their kids being ill and they were discussing how they "just called and had Amy write them a script for a Z-pack". The Bragger turned to me and said "gosh...it's so nice having a doctor for a friend".

Amy (whom both of them are friends with) is their DENTIST...not their doctor.

They went on and on how nice it is to just "call Amy and have her write it up" and go get a prescription whenever they need it. She had apparently written one for every member in the one household as walking pneumonia and some other illness had been spreading through their house. The Bragger said she had a UTI and her daughter had some sort of a cold (she's 1) and she just wrote one for them too.

I have to admit I'm a little jealous that they don't have to pay the co-pay and go to the doctor but I'm just wondering...is this really ok? I don't know that it's illegal...but wouldn't a pharmacist question this? When you see a script for a 1 year old for a Z pack- wouldn't you wonder what kind of dental treatment would be required on a child that age?

Is it illegal...unethical (as in she could really get in trouble...not just morally)?

 

[QVCshopper]

I'll dare to answer. I have dentists in the family and my FIL once wrote a script for my DD's pink eye; we were far away from home and didn't have a doctor we could go to. Another othodonist I know called in a script for a z-pack for his DD (she was home, he was in the bahamas). So, I know it's done.

That said, my DD just got pink eye this weekend and we took her to the peditrician. I don't like abusing my FIL's ability, and would like to save it for extreme circumstances. But, I can tell you that your friends' dentist buddy isn't alone. And I don't really see it as fraud.

BTW-most dentists technically are doctors; my FIL, BIL, and SIL are DMDs--Doctor of Medical Dentistry.

 

[Kay1]

It's not something I would worry about. When my BIL was visiting us one of my sons seemed to need an antibiotic. He phoned in a prescription and told the pharmacy he was a doctor and would be picking it up himself so he got a discount.

When I was in Respiratory Therapy, I got lots of prescriptions from doctors I worked with and one surgeon offered to remove a cyst for me in an ER room. Professional courtesy.

OTOH, yours involves a dentist and that may be different. Wasn't there a Seinfeld episode in which a dentist got in trouble for prescribing massages to his friend? Hmmm . . .

 

[princessmom29]

It's not fraud. The dentist has despensing privliges, and the insurance compan would rather just pay for the perscription than the doctor's visit and perscription. They are actually saving the insurance company money, not costing them anything.

 

[MomToOne]

I don't think it's fraud of any type.

But my SIL is a doctor, and I don't take advantage of her that way

 

[ceecee]

That to me is putting "Amy" on the spot. Since she is a friend of theirs I think that's wrong to even ask. Also they may not get a diagnosis of what is really the illness. She is allowed to write an Rx so it doesn't effect premiums in any way. A dentist in our area did get into trouble for writing pain Rxs for people (most weren't even his pts).

 

[dumbocutie]

I feel it contributes to the cause of the antibiotic resistent strains of bacteria out there. The abuse of over perscribing antibiotics is causing super bugs that can not be treated. When people get perscriptions without even being looked at by a doctor to confirm they need an antibiotic.

We are going to see a rise in drug resistent bacteria. This is only the beginning. Here is an excerpt from CDC.

Why should I be concerned about antibiotic resistance?
A: Antibiotic resistance has been called one of the world's most pressing public health problems. Almost every type of bacteria has become stronger and less responsive to antibiotic treatment when it is really needed. These antibiotic-resistant bacteria can quickly spread to family members, schoolmates, and co-workers - threatening the community with a new strain of infectious disease that is more difficult to cure and more expensive to treat. For this reason, antibiotic resistance is among CDC's top concerns.

Antibiotic resistance can cause significant danger and suffering for children and adults who have common infections, once easily treatable with antibiotics. Microbes can develop resistance to specific medicines. A common misconception is that a person's body becomes resistant to specific drugs. However, it is microbes, not people, that become resistant to the drugs.

If a microbe is resistant to many drugs, treating the infections it causes can become difficult or even impossible. Someone with an infection that is resistant to a certain medicine can pass that resistant infection to another person. In this way, a hard-to-treat illness can be spread from person to person. In some cases, the illness can lead to serious disability or even death.



Q: Why are bacteria becoming resistant to antibiotics?
A: Antibiotic use promotes development of antibiotic-resistant bacteria. Every time a person takes antibiotics, sensitive bacteria are killed, but resistant germs may be left to grow and multiply. Repeated and improper uses of antibiotics are primary causes of the increase in drug-resistant bacteria.

While antibiotics should be used to treat bacterial infections, they are not effective against viral infections like the common cold, most sore throats, and the flu. Widespread use of antibiotics promotes the spread of antibiotic resistance. Smart use of antibiotics is the key to controlling the spread of resistance.

Antibiotics kill bacteria, not viruses
Q: How do bacteria become resistant to antibiotics?
A: Antibiotic resistance occurs when bacteria change in some way that reduces or eliminates the effectiveness of drugs, chemicals, or other agents designed to cure or prevent infections. The bacteria survive and continue to multiply causing more harm. Bacteria can do this through several mechanisms. Some bacteria develop the ability to neutralize the antibiotic before it can do harm, others can rapidly pump the antibiotic out, and still others can change the antibiotic attack site so it cannot affect the function of the bacteria.

Antibiotics kill or inhibit the growth of susceptible bacteria. Sometimes one of the bacteria survives because it has the ability to neutralize or escape the effect of the antibiotic; that one bacterium can then multiply and replace all the bacteria that were killed off. Exposure to antibiotics therefore provides selective pressure, which makes the surviving bacteria more likely to be resistant. In addition, bacteria that were at one time susceptible to an antibiotic can acquire resistance through mutation of their genetic material or by acquiring pieces of DNA that code for the resistance properties from other bacteria. The DNA that codes for resistance can be grouped in a single easily transferable package. This means that bacteria can become resistant to many antimicrobial agents because of the transfer of one piece of DNA.

The Food and Drug Administration's (FDA's) Center for Veterinary Medicine (CVM) produced a nine-minute animation explaining how antimicrobial resistance both emerges and proliferates among bacteria. Over time, the use of antimicrobial drugs will result in the development of resistant strains of bacteria, complicating clinicians' efforts to select the appropriate antimicrobial for treatment.



Q: How can I prevent antibiotic-resistant infections?
Only use antibiotics when they are likely to be beneficial
A: By visiting this website, you are taking the first step to reducing your risk of getting antibiotic-resistant infections. It is important to understand that, although they are very useful drugs, antibiotics designed for bacterial infections are not useful for viral infections such as a cold, cough, or the flu. Some useful tips to remember are:

1.Talk with your healthcare provider about antibiotic resistance:
•Ask whether an antibiotic is likely to be beneficial for your illness
•Ask what else you can do to feel better sooner
2.Do not take an antibiotic for a viral infection like a cold or the flu.
3.Do not save some of your antibiotic for the next time you get sick. Discard any leftover medication once you have completed your prescribed course of treatment.
4.Take an antibiotic exactly as the healthcare provider tells you. Do not skip doses. Complete the prescribed course of treatment even if you are feeling better. If treatment stops too soon, some bacteria may survive and re-infect.
5.Do not take antibiotics prescribed for someone else. The antibiotic may not be appropriate for your illness. Taking the wrong medicine may delay correct treatment and allow bacteria to multiply.
6.If your healthcare provider determines that you do not have a bacterial infection, ask about ways to help relieve your symptoms. Do not pressure your provider to prescribe an antibiotic.

 

[MrsJackSparrow4Life]

Don't Dentists have to go through med school the same as regular doctors? I thought they were the same as any other specialist; go through med school and then get the extra training for your chosen field.

If it was someone I knew well and who knew what they were doing, I would have no problem doing this.

As for it being insurance fraud, I doubt the insurance companies are going to be upset about not having to pay for their portion of a doctor's visit.

 

[MommaSnowwhite]

I don't think any Doctor is setting themselves up for liability problems when they write Rx's for people they are not currently treating. What if they wrote a script for an antibiotic and that isn't the correct treatment for what is really making them sick?

I personally think it is a bad practice.

 

[disneypharm]

Not sure what state you are in, the Illinois State Dental Society says the paragraph below. I am sure there are similar rules in other states. Of course a dentist can easily say that an antibiotic is required for the dental work. Pain medications (controlled substances) are a different story. That's when most of the doctors get in trouble for prescribing too much.

"Prescription Writing Authority

Licensed dentists in Illinois may write prescriptions only in connection with dental-related ailments or conditions. To write a prescription for any other non-dental condition is a violation of the Illinois Dental Practice Act and may make the dentist liable for license sanction."

 

[Lisa loves Pooh]

It's not fraud. The dentist has despensing privliges, and the insurance compan would rather just pay for the perscription than the doctor's visit and perscription. They are actually saving the insurance company money, not costing them anything.

I don't think it's fraud of any type.

But my SIL is a doctor, and I don't take advantage of her that way

Not insurance fraud, but most likely illegal/unethical as the Dentist is not licensed to treat non-dental related conditions. And antibiotics aren't ever to be prescribed for a cold as those are viral. Any physician would know that.

Don't Dentists have to go through med school the same as regular doctors? I thought they were the same as any other specialist; go through med school and then get the extra training for your chosen field.

If it was someone I knew well and who knew what they were doing, I would have no problem doing this.

As for it being insurance fraud, I doubt the insurance companies are going to be upset about not having to pay for their portion of a doctor's visit.

No--they go to Dental School only. Dental schools are set up completely separate from medical schools.

Here is the Dental Curriculum for the UF dental school (for point of reference). You will notice that the curriculum is mostly "limited" to the head area where the teeth are located. There is 1 gross anatomy class that covers the whole body. http://www.dental.ufl.edu/Offices/Education/Grad/Curriculum.php

Contrast that to the first year of medical school: http://medinfo.ufl.edu/year1/

Insurance companies might get upset that they have to pay for any complications arising from a misdiagnosis.

 

[Halle]

Dentists do not go through the same training as MD's. It is not smart for anyone to ask for a prescription from a friend. Taking an antibiotic without being diagnosed could potentially mask an illness....happened to DF's son, he almost died.

 

[GinnyEmma]

As far as the super bug theory, some infection specialists are saying this is not necessarily the case. Meds like doxycyline are still something like 95% effective, 30 years later. Per the speaker at the symposium i went to. Sorry too lazy to go find the material for reference.

So it seems it is simplistic to make broad brush statements, imo.

 

[jaminmd]

I feel it contributes to the cause of the antibiotic resistent strains of bacteria out there. The abuse of over perscribing antibiotics is causing super bugs that can not be treated. When people get perscriptions without even being looked at by a doctor to confirm they need an antibiotic.

We are going to see a rise in drug resistent bacteria. This is only the beginning. Here is an excerpt from CDC.

Why should I be concerned about antibiotic resistance?
A: Antibiotic resistance has been called one of the world's most pressing public health problems. Almost every type of bacteria has become stronger and less responsive to antibiotic treatment when it is really needed. These antibiotic-resistant bacteria can quickly spread to family members, schoolmates, and co-workers - threatening the community with a new strain of infectious disease that is more difficult to cure and more expensive to treat. For this reason, antibiotic resistance is among CDC's top concerns.

Antibiotic resistance can cause significant danger and suffering for children and adults who have common infections, once easily treatable with antibiotics. Microbes can develop resistance to specific medicines. A common misconception is that a person's body becomes resistant to specific drugs. However, it is microbes, not people, that become resistant to the drugs.

If a microbe is resistant to many drugs, treating the infections it causes can become difficult or even impossible. Someone with an infection that is resistant to a certain medicine can pass that resistant infection to another person. In this way, a hard-to-treat illness can be spread from person to person. In some cases, the illness can lead to serious disability or even death.



Q: Why are bacteria becoming resistant to antibiotics?
A: Antibiotic use promotes development of antibiotic-resistant bacteria. Every time a person takes antibiotics, sensitive bacteria are killed, but resistant germs may be left to grow and multiply. Repeated and improper uses of antibiotics are primary causes of the increase in drug-resistant bacteria.

While antibiotics should be used to treat bacterial infections, they are not effective against viral infections like the common cold, most sore throats, and the flu. Widespread use of antibiotics promotes the spread of antibiotic resistance. Smart use of antibiotics is the key to controlling the spread of resistance.

Antibiotics kill bacteria, not viruses
Q: How do bacteria become resistant to antibiotics?
A: Antibiotic resistance occurs when bacteria change in some way that reduces or eliminates the effectiveness of drugs, chemicals, or other agents designed to cure or prevent infections. The bacteria survive and continue to multiply causing more harm. Bacteria can do this through several mechanisms. Some bacteria develop the ability to neutralize the antibiotic before it can do harm, others can rapidly pump the antibiotic out, and still others can change the antibiotic attack site so it cannot affect the function of the bacteria.

Antibiotics kill or inhibit the growth of susceptible bacteria. Sometimes one of the bacteria survives because it has the ability to neutralize or escape the effect of the antibiotic; that one bacterium can then multiply and replace all the bacteria that were killed off. Exposure to antibiotics therefore provides selective pressure, which makes the surviving bacteria more likely to be resistant. In addition, bacteria that were at one time susceptible to an antibiotic can acquire resistance through mutation of their genetic material or by acquiring pieces of DNA that code for the resistance properties from other bacteria. The DNA that codes for resistance can be grouped in a single easily transferable package. This means that bacteria can become resistant to many antimicrobial agents because of the transfer of one piece of DNA.

The Food and Drug Administration's (FDA's) Center for Veterinary Medicine (CVM) produced a nine-minute animation explaining how antimicrobial resistance both emerges and proliferates among bacteria. Over time, the use of antimicrobial drugs will result in the development of resistant strains of bacteria, complicating clinicians' efforts to select the appropriate antimicrobial for treatment.



Q: How can I prevent antibiotic-resistant infections?
Only use antibiotics when they are likely to be beneficial
A: By visiting this website, you are taking the first step to reducing your risk of getting antibiotic-resistant infections. It is important to understand that, although they are very useful drugs, antibiotics designed for bacterial infections are not useful for viral infections such as a cold, cough, or the flu. Some useful tips to remember are:

1.Talk with your healthcare provider about antibiotic resistance:
•Ask whether an antibiotic is likely to be beneficial for your illness
•Ask what else you can do to feel better sooner
2.Do not take an antibiotic for a viral infection like a cold or the flu.
3.Do not save some of your antibiotic for the next time you get sick. Discard any leftover medication once you have completed your prescribed course of treatment.
4.Take an antibiotic exactly as the healthcare provider tells you. Do not skip doses. Complete the prescribed course of treatment even if you are feeling better. If treatment stops too soon, some bacteria may survive and re-infect.
5.Do not take antibiotics prescribed for someone else. The antibiotic may not be appropriate for your illness. Taking the wrong medicine may delay correct treatment and allow bacteria to multiply.
6.If your healthcare provider determines that you do not have a bacterial infection, ask about ways to help relieve your symptoms. Do not pressure your provider to prescribe an antibiotic.

BINGO! This is exactly the problem that occurs when antibiotics are used unnecessarily. That's how we get "superbugs" like MRSA & VRE.

I'm an infection prevention & control nurse, so I fight this battle on a daily basis. The other problem with the scenario you describe is the fact that they are writing prescriptions for illnesses that have not been diagnosed by an MD, PA, or CRNP as well as never directly examining the patient. Dentists should write for dental related issues, not pneumonia.

 

[jaminmd]

As far as the super bug theory, some infection specialists are saying this is not necessarily the case. Meds like doxycyline are still something like 95% effective, 30 years later. Per the speaker at the symposium i went to. Sorry too lazy to go find the material for reference.

So it seems it is simplistic to make broad brush statements, imo.

Sorry, your facts are wrong and your statement is far too simplistic. Infectious disease specialists make no such argument. Doxcycline is one of many antibiotics and may be sensitive to a broad spectrum of bacteria.

However, over use of antibiotics over the last few decades has caused multi drug resistance. Carbapenem-resistant Enterobacteriaceae are on the rise. Think of carbapenems as the last line of defense in antibiotics. We have bacteria resistant to these, the strongest of antibiotics. That leaves nothing to treat patients with.

 

[disneypharm]

Sorry, your facts are wrong and your statement is far too simplistic. Infectious disease specialists make no such argument. Doxcycline is one of many antibiotics and may be sensitive to a broad spectrum of bacteria.

However, over use of antibiotics over the last few decades has caused multi drug resistance. Carbapenem-resistant Enterobacteriaceae are on the rise. Think of carbapenems as the last line of defense in antibiotics. We have bacteria resistant to these, the strongest of antibiotics. That leaves nothing to treat patients with.

Yes, I agree

 

[scrapquitler]

Anyway, her and another neighbor of ours (who DOESN'T always do the "my friends are so rich game) were friends before they moved into our cul-de-sac. We were all 3 talking in our yards the other day about their kids being ill and they were discussing how they "just called and had Amy write them a script for a Z-pack". The Bragger turned to me and said "gosh...it's so nice having a doctor for a friend".

Amy (whom both of them are friends with) is their DENTIST...not their doctor.

I don't think there's an issue. I imagine that "Amy" isn't billing anyones insurance, so there's no fraud there. I doubt that a medical professional would write prescriptions that would jeopardize their license for something as simple as a Zpack, so there must not be an issue.

And anyway, its none of your business.

 

[disneypharm]

I don't think there's an issue. I imagine that "Amy" isn't billing anyones insurance, so there's no fraud there. I doubt that a medical professional would write prescriptions that would jeopardize their license for something as simple as a Zpack, so there must not be an issue.

And anyway, its none of your business.

Maybe "Amy" thinks it's ok for her to write a ton of prescriptions for friends and family. The issue is not only with the insurance company. She might get in trouble with the Board of Dentistry. See below:
"Prescription Writing Authority

Licensed dentists in Illinois may write prescriptions only in connection with dental-related ailments or conditions. To write a prescription for any other non-dental condition is a violation of the Illinois Dental Practice Act and may make the dentist liable for license sanction."

 

[threecrazykids]

I don't think there's an issue. I imagine that "Amy" isn't billing anyones insurance, so there's no fraud there. I doubt that a medical professional would write prescriptions that would jeopardize their license for something as simple as a Zpack, so there must not be an issue.
And anyway, its none of your business.

Well...first off...the bolded...to doubt that a medical professional would write prescriptions that would jeopardize their license?...people get prescriptions all the time from physicians they technically shouldn't have...granted they are mostly narcotics, not an antibiotic.

And as far as it being none of my business...I know it's not...that's why I came here and didn't question the women themselves.

 

[3boymthr]

Okay, weighing in from the insurance professional's perspective. I'm an insurance underwriter for medical, dental and prescription plans by profession (17 years underwriting experience for both fully insured and self funded plans). The insurance company will pay any prescription as long as the practitioner is licensed to write the script, even if said script writer is a dentist. If you've ever noticed dental scripts related to pain relief, preventive anti-biotics for extractions, etc. go thru your medical insurance not your dental insurance and they're covered; as far as insurance is concerned a script is a script is a script. As long as the dr., dentist or NP has a valid federal ID, and their ID allows them to issue a script for that drug, it's all good (it's the responsibility of the pharmacy to verify the ID.)

Be aware, that it is not insurance companies that dictate you must go in for the office visit just to get a script, be it for pink eye or a respiratory infection, it's your doctor. Insurance companies do not match up scripts to doctors visits. That would be impossible because there are in fact, many, many, many scripts that are issued without a doctors visit (think of all those visits for something like an ear infection where the doctor says to you if this isn't better in two days call us back and you do and they change your script with no add'l visit). In fact it actually works to the insurance company's advantage for your neighbors to be calling their friend as for the most part it's saving the insurance co. money. Your friends are getting the benefit of a drs. services with out your neighbors having to pay the co-pay and without the insurance co having to pay for balance of the office visit. (Plus not only is the insurance company saving money on the payment of the claim but on the processing of the claim.)

ETA - I should say any "covered" script. Because there are some drugs that aren't covered medications and there are some drugs that are only covered if administered at a clinic or hospital, etc.