Reimbursement Diagnoses May Be Co-Morbid: Ethical Concerns with Different Diagnoses

By Thomas G. Plante, Ph.D., ABPP
May 5, 2016 - Last updated: May 4, 2016

Disclosures for Forensic Evaluations: Not an Assessment for Purposes of TreatmentI work in a sleep medicine clinic. Since the implementation of ICD-10-CM, I have had more cases where the diagnosis (for example: insomnia) is not accepted by insurance. My billing person has asked me for another diagnosis so she can rebill insurance. There are some cases where all I can do is give a different diagnosis that had not been documented before in the chart. Is this ethical? At my private practice, I have paper charts. I wondered if you have general guidelines about whether you can do an addendum to your note, or how I should handle giving a new diagnosis. I don’t give a diagnosis unless I feel that it applies, and I always keep my original diagnosis that applies the best in every note. Are there other ethical issues I should be considering?

This is a vitally important issue that impacts most practicing psychologists as well as most other mental health care professionals. The posed dilemma also well illustrates the potentially conflicting ethical concerns faced by clinicians in these challenging scenarios. Finally, in addition to the ethical challenges involved with this situation there are many legal, professional and institutional policy and procedure concerns that must be taken into consideration as well.

Using the RRICC model of ethical decision making (i.e., Respect, Responsibility, Integrity, Competence and Concern; Plante, 2004) which distills the ethical guidelines and codes from psychology and the other mental health care professions, the professional has a responsibility to provide quality, state-of-the-art and competent service in diagnostics and treatment while following all legal, ethical and institutional guidelines and policies. They also need to conduct themselves with the highest level of integrity and with concern for those with whom they work.

Yet, conflicts do arise and in this case the professional is trying to balance his concern for the patient and institution to get paid for the services rendered by the insurance carrier, yet do so without engaging in insurance fraud or dishonest deception. Insurance policies often pay for diagnoses that are deemed as “medical necessities” and in this particular case, it appears that insomnia is not sufficiently and medically problematic enough to warrant insurance reimbursement according to the specific insurance carrier.

Certainly most clinical diagnostic and treatment cases have co-morbidity and so the patient with insomnia may also legitimately experience a co-morbid anxiety, depressive, substance abuse or other psychiatric or psychological disorder. While insomnia may not be reimbursable in this case, one or more of the co-morbid disorders might very well be reimbursable.

Additionally, a diagnostic understanding of the case can and likely evolves over time and thus adding or eliminating previously considered diagnoses is reasonable and expected in clinical care. Therefore, it is possible that the clinician can ethically, clinically and professionally work around the dilemma of insurance reimbursement by attending to, documenting and treating co-morbid conditions and by updating the clinical notes to reflect the unfolding diagnostic understanding and case formulation associated with this particular patient.

It is also important to mention that the patient must have clear informed consent in language that is understandable regarding the potential limits of insurance reimbursement based on diagnosis and treatment planning.

It is inevitable that conflicts between the professional and ethical guidelines for clinicians and those of the institution’s billing office will occur and may occur frequently. Making our ethical guidelines and expectations known to others in a compassionate and easy to understand manner may help to smooth conflictual goals and desire among all parties.

We cannot expect non-mental health professionals, such as business professionals, to follow the same ethical guidelines that we do or to fully understand those articulated in our professional codes of conduct. Yet we are expected to work with many people with diverse sets of goals and expectations. Helping others to understand our professional ethics in a thoughtful and compassionate manner helps to create the collegial problem solving approach that best serves our patients and ourselves.

At the end of the day, we always must act with integrity – never being deceptive or dishonest and thus must be truthful with our diagnostic work with or without the pressures of the various rules associated with insurance reimbursement. Yet we also must maintain our integrity with a careful eye toward concern for others, our competence level, our respect for all parties involved who are entrusted with our care and our responsibility to our patients, our institutions of employment and to our profession.

When we do the right thing, we may or may not secure the maximum insurance benefits – or other benefits for that matter. Sometimes following our ethical principles and code do have costs involved, but I always contend that the costs are worth it and that we usually are grateful for them later when the dust settles on our ethical and professional challenges in the moment. For additional information specific to the APA Code of Ethics see section 6.06, Accuracy in reports to payers and funding sources.


Share Button

Thomas G. Plante, Ph.D., ABPP, is the Augustin Cardinal Bea, SJ University Professor at Santa Clara University, clinical adjunct professor of psychiatry at Stanford University and maintains a clinical practice in Menlo Park, Calif. He teaches, writes and consults on ethics as well as religious and spiritual issues. He is the author of Do the right thing: Living ethically in an unethical world (New Harbinger 2004). His email is:

Related Articles