Is this insurance fraud? Unethical or illegal?

[3boymthr]

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."

Yes, but dentists write scripts for anti-biotics all the time, so realistically, no one (monitoring agency or pharmacy) would question a dentist writing a script for a z-pack. And if they did, all she'd have to say is that they had an infected tooth or gum.

 

[threecrazykids]

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.)

Well there's my answer then...I guess I just was thinking it was "unethical" as she isn't a doctor...but a dentist. I assume she just uses her best judgement that whatever their symptoms are must warrant ok'ing a script.

 

[disneypharm]

Yes, but dentists write scripts for anti-biotics all the time, so realistically, no one (monitoring agency or pharmacy) would question a dentist writing a script for a z-pack. And if they did, all she'd have to say is that they had an infected tooth or gum.

Yes, in my first response (on the first page) I said the same thing. She can always say that the antibiotic is for dental-related issues; however, if she keeps writing prescriptions (especially controlled meds - not knowing if she does that) for her friends, she might eventually get in trouble.

 

[beansmom]

frankly, it is the doctor's responsibility to know what they can and can't do...my dh would NEVER risk his license prescribing inappropriately for anyone. OTOH, people shouldn't take advantage of professionals, either....but again, it's the professional who is responsible for drawing the line.

 

[Mama Who]

There's not an insurance issue on the patient's end, but the dentist might well get sharp words from the certifying board and their own malpractice insurance carrier.

 

[3boymthr]

Well there's my answer then...I guess I just was thinking it was "unethical" as she isn't a doctor...but a dentist. I assume she just uses her best judgement that whatever their symptoms are must warrant ok'ing a script.

Yeah, ethically this dentist should not be writing scripts for them. And if you are truly concerned about the ethics of what she is doing then you can report her to your state's dental governing board.

I will note that if she were brought up on charges for writing illegal scripts, well then the insurance company might (and this is a big might) go back and analyze all the scripts that they paid out that were written by her, and they might ask for verification of the visit and or dx for the script but you have to understand that most insurance companies pay out on over one million scripts per year so they probably wouldn't do this unless this dentist was writing hundreds and hundreds of illegal scripts or unless they were asked to by the dental board.

I think from a payment perspective as to why these get paid without any question as to whom is writing the script, it may help to know that most insurance companies (such as BCBS or Cigna or your local TPA - especially small TPAs) don't actually pay 99.99% of prescription costs anymore, rather prescriptions are managed by PBMs (pharmacy benefit managers - aka Express-Scripts, Wellpoint, CVS) who have electronic connections set up with the pharmacies and who after the scripts are issued funnel the charges and script data back to the insurance company at set periods of time, be it daily, weekly, monthly or quarterly, (generally not daily and most commonly monthly) depending upon the size of the PBM and the size of the insurance company. In addition, in all my years of working in insurance I have never ever been involved in a scenario where we questioned either the number of scripts written by a particular provider nor the type of scripts written by a particular provider nor even by any particular class of provider (also please don't forget there are other non "doctor" providers besides dentists who can write scripts too.)

 

[Celidh]

I can't say whether it is right or wrong for the "dentist" to be writing these, nor can I comment about the insurance.

What I would say is what parent in their right mind would want their child to be treated and given a prescription by someone who isn't qualified to diagnose them properly. What if "Amy" gave a prescription for walking pneumonia but it was something worse. I have a daughter with mild asthma, who has spent 3 days in the hospital on oxygen for her breathing when she had pneumonia and was admitted overnight another time. After her getting a steroid puffer (which can make her hyper) at the doctor's office and then sent to the hospital, the nurse in the emerg commented that she looked fine to her because she was running around. Well, she was admitted that day stayed hooked to oxygen for days. My oldest son also spent time in the hospital for pneumonia and he has no health issues. As it was, the ER docs missed his pneumonia on a Friday but then when we took him back on Sunday after we couldn't keep his fever down and it hurt to breath, he was admitted after they did a second chest xray. Nope, wouldn't want the dentist looking after them.

I would never want my dentist to prescribe anything that wasn't for dental work. If this was a poor neighbourhood where your acquaintances were desperate for healthcare I could possibly see this but somehow I don't think that is the case here. If my children are sick, I want them looked after properly. Alas, I live in Canada where I don't have to worry about the cost of going to the doctor, just the 2 or 3 week wait to get in to see the doctor!

 

[disfan07]

I can't say whether it is right or wrong for the "dentist" to be writing these, nor can I comment about the insurance.

What I would say is what parent in their right mind would want their child to be treated and given a prescription by someone who isn't qualified to diagnose them properly. What if "Amy" gave a prescription for walking pneumonia but it was something worse. I have a daughter with mild asthma, who has spent 3 days in the hospital on oxygen for her breathing when she had pneumonia and was admitted overnight another time. After her getting a steroid puffer (which can make her hyper) at the doctor's office and then sent to the hospital, the nurse in the emerg commented that she looked fine to her because she was running around. Well, she was admitted that day stayed hooked to oxygen for days. My oldest son also spent time in the hospital for pneumonia and he has no health issues. As it was, the ER docs missed his pneumonia on a Friday but then when we took him back on Sunday after we couldn't keep his fever down and it hurt to breath, he was admitted after they did a second chest xray. Nope, wouldn't want the dentist looking after them.

I would never want my dentist to prescribe anything that wasn't for dental work. If this was a poor neighbourhood where your acquaintances were desperate for healthcare I could possibly see this but somehow I don't think that is the case here. If my children are sick, I want them looked after properly. Alas, I live in Canada where I don't have to worry about the cost of going to the doctor, just the 2 or 3 week wait to get in to see the doctor!

I'm finding those waits are not unique to Canada at all. My derm. is completely booked for the next 3 weeks for established patients. For new patients, it's a 5 week wait (at least). My internist has a 4 month wait for new patients. My GYN is also completely booked for the next 3 1/2 weeks. And I still have to pay! The only time I have not waited 2-3 weeks for a specialist was for my neurosurgeon and that was because my neurologist called him and told him it was urgent. With my neurologist, when I had to make my 3 month follow-up he was already almost completely booked. Apparently the fact that my docs. are so wonderful is not a secret around here!

 

[Evi]

how is it insurance fraud?? is it that your bothered that they know someone who can prescribe them medication without having to make a dr appt and pay for insurance premium?? I doubt the friend was billing them for a visit. Honestly I don't get that into what my neighbors talk about. There life is there life.

 

[ExPirateShopGirl]

I was raised in a family of medical professionals; dentists and physicians. I have been fortunate enough to have prescriptions called in by several of them when I wasn't able to make it in to my own physician or to a pediatrician for my kids, mostly by my own father. Never for anything other than antibiotics. I try not to make it a habit. They call me for legal advice far more often than i call for a script... lol

 

[Aliceacc]

I think self-diagnosis is dangerous if you're not a professional.

It's less about who is writing the prescription, in my opinion,than who is deciding what's wrong and how best to handle it.

 

[tomthebarncat]

I think it is unethical to write prescriptions for people you have not seen. My sister who is CEO of 5 medical schools, agrees. The military has a policy that you cannot write prescriptions for family members, and it is enforced, as my ex is a MD, PHD, and does see patients but it is considered a conflict of interest and I agree.

 

[pigletto]

I'm not certain if it is merely unethical here or actually illegal, but I do know that a very close family member will NOT treat us, write scripts for us or take us on as patients. She in fact has been known to tell non family friends that she can be their practioner or their friend, but not both as it is a conflict of interest. Whether it is frowned upon or an actual law I am unsure. But I do know that I respect this persons work ethic and integrity.

The situation you are describing leaves a bad taste in my mouth regarding this dentist. You don't treat people with no knowledge of their history and certainly not sight unseen.

 

[lost*in*cyberspace]

The military has a policy that you cannot write prescriptions for family members,

Really? I know of several military doctors who write prescriptions for their family members and have done so for years.

To the OP - who cares? It's really none of your business what your neighbors are doing regarding filling their prescriptions.

 

[jackskellingtonsgirl]

I don't really see how it's a problem. The dentist isn't giving them drugs under the table - she is writing prescriptions. Those drugs are running through her DEA number, so she is aware they can be traced back to her.

I am currently on antibiotics for an eye infection. My family Dr. authorized the meds over the phone - I didn't go in and pay for an office visit. I don't really see what difference it makes who writes the prescription. I have had the same med from the eye Dr. but this time it was easier to get ahold of my regular Dr. and have her call it in. My eye does this all the time, and the faster I can treat it the better the results

 

[threecrazykids]

Really? I know of several military doctors who write prescriptions for their family members and have done so for years.

To the OP - who cares? It's really none of your business what your neighbors are doing regarding filling their prescriptions.

I believe I've already stated that yes, I know it's not any of my business...hence the reason I didn't say a word when they were discussing it.

Sheesh, I just am asking for people's opinions on what their thoughts are...why do people get so up in arms when someone is simply asking opinions on here? I'm not planning on taking any action or turning her in...I'm simply asking whether people feel it's ethical or not. 99% of what people post on these boards are opinions, but really not their business.

 

[tomthebarncat]

Really? I know of several military doctors who write prescriptions for their family members and have done so for years.

To the OP - who cares? It's really none of your business what your neighbors are doing regarding filling their prescriptions.

My ex is active duty Army and their policy was very clear at the time, no can do!! I have been divorced and remarried for 10 years, so I have no idea what the current policy is, nor do I care. I still think it is unethical and I would not jeapordize my licensing, credentials and several hundred thousand dollars worth of education, to write a script for a non patient, but that is just me. I really could care less what others are doing, as I have nothing to gain or lose by their actions.

 

[teacup princess]

It is unethical for a prescriber to write a prescription for a person with which they have no professional relationship (ie: do not know or have not examined). Doctors do write for family members or themselves all the time and mostly I don't have a problem with that because they usually are aware of their family member's medical issues and have examined them to some degree.

It is illegal/unethical for a dentist or other prescriber to write a presciption for a medical issue outside of their normal scope of practice. Therefore, a dentist should not be writing prescriptions for respiratory problems, eye infections, ect. A pharmacist should refuse to fill prescriptions from dentists for eyedrops, birth control pills, ect.. since those are for conditions outside of the dentists normal scope of practice. If the dentist is writing for a z-pak it's logical that the z-pak could be used for a dental issue so the prescription would probably not be questioned and would get filled by the pharmacy, but your neighbor is putting her friend's dental license at risk by asking her to prescribe for her family's medical issues.

 

[tnd]

I think it is unethical to write prescriptions for people you have not seen. My sister who is CEO of 5 medical schools, agrees. The military has a policy that you cannot write prescriptions for family members, and it is enforced, as my ex is a MD, PHD, and does see patients but it is considered a conflict of interest and I agree.

My husband is an ER doc and will not write RXs for me or our kids. As to the OP's question, I don't think having a dentist write an RX is fraudulent or illegal. The ethical issue may be a closer question, but that's for the dentist to worry about. I would not want a script from someone who hadn't examined the patient however.

 

[bumbershoot]

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.

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.

I agree.

And while in chiropractic school I dealt with a problem situation. Embarrassing one, though I was vindicated so I'll tell it. A boyfriend, soon to be ex, went up north for a bachelor party for a friend. When he got home, he decided he had some sort of infection. He called his home doctor (we were in SC, doctor was in NY), described what was going on, the doctor made a diagnosis of something embarrassing and called down a prescription. He then berated ME for giving him this infection. Even though he was the one who'd been at the bachelor party but whatever. I actually went to see a doctor, in person, had lab work done. The lady that saw me said "since a doctor prescribed him something he probably does have it you shold take this". I did...and just as I finished the grueling round of antibiotics (never been so sick on them!) the results came in...I didn't have it.

Doctors prescribing by phone for non-chronic illnesses without current labwork proving you need the drugs is an idiotic mistake. Flat out, period, end of story.

And antibiotics aren't ever to be prescribed for a cold as those are viral. Any physician would know that.

Wouldn't you think so? Alas, a hospital full of doctors and nurses gave my half-brother a HUGE amount of antibiotics when he had the big bad nasty scary h1n1 flu (well he got the quick test diagnosis, which I have heard gives some nice false positives, so IMO we'll never know if it's what he really had). Flu and antibiotics? You'd really think they would have known better, wouldn't you?

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.

How is azithromycin simple? It's a 10 day prescription worth of antibiotics packed into 5 days. I wouldn't call a 10 day prescription of antibiotics simple.

There's not an insurance issue on the patient's end, but the dentist might well get sharp words from the certifying board and their own malpractice insurance carrier.

I agree.

And I'd be totally happy to call Amy's licensing board about it. When I had a license to practice I took things seriously, and I take the licenses of others seriously as well. Someone who can't follow their licensing board doesn't deserve to have that license.