Don't Lose Your License! Ethical Dilemmas in Dispensing

By Mary Field

If a question pops up often enough you have to believe that those who ask are only the tip of the iceberg. Lately, many people have been asking questions related to ethics, specifically on how to deal with requests from consumers to sign fraudulent vision care insurance claims. The answer sounds simple. Don’t do it! You’re jeopardizing your license. You’re committing an illegal act. But sometimes it doesn’t seem so easy to see the right and wrong.

Some time ago I gave a series of lectures on Situational Ethics. It’s a topic that’s as relevant now as it was a decade ago. Simply put, ethics is a collection or a system of moral principles upon which you base your actions. It’s what you believe to be right or wrong. Situational ethics refer to how you apply that system of moral principles when challenged by different circumstances.

Most people are able to identify the application of ethical principles (or lack of same) in others without too much trouble. The ethical line becomes more blurred when applied to personal situations.

The first ethical factoid is: Sticking to a code of ethics sometimes involves acting against your own self-interest.

It’s easy to see how self-interest swayed decision-making in the following instances.

As of this writing a House of Commons committee is holding hearings about whether or not former Prime Minister Brian Mulroney behaved unethically in accepting large sums of money from a lobbyist during the period of time he was Prime Minister. He had previously stated under oath that he hadn’t received any money from the gentleman in question. Now it has come to light that in fact Mr. Mulroney did receive large sums of money while he was Prime Minister. Mr. Mulroney has admitted this and termed it “a serious error of judgment.” (Quoted from Maclean’s Magazine)

Martha Stewart spent time in jail for taking advantage of insider information to sell stocks in a company called Imclone. Her stockbroker had received important information from the owner of Imclone that was going to cause the stock to drop dramatically once it became public knowledge. The stockbroker shared that information with Martha and she dumped her stock, thereby avoiding the substantial loss of money that would have occurred had she still owned the stock when the value went down. The stockbroker, the owner and Stewart all knew what they did was illegal but…they did it anyway because the action was in their self-interest.

Imagine these scenarios much closer to home. Perhaps some of you have lived through them.

• Your customer says that he’s been paying into the company health care plan for many years and that although his children are entitled to prescription glasses they don’t need them. Consequently he isn’t receiving the same benefit from the plan that his workmate with three eyeglasses-wearing children is receiving. What he wants you to do is to make him the glasses but say on the claim that the glasses are for his son.
• Same customer. This time he wants the claim in his son’s name but since the child doesn’t need a prescription he wants you to sell him plano Oakley sunglasses and sign the vision care claim form as if it was for a prescription.
• Your customer’s vision care plan doesn’t cover contact lens solutions so she asks you to add the price of the solutions to the price of the contact lenses so she can get full value for her claim.
• Your customer is not currently covered by a vision care plan but will be starting employment in one month at a company where she will be covered. However she needs her glasses and contact lenses now and is willing to pay you now but wants you to post date the receipt or write a duplicate receipt when the time comes. (The reverse of this one is that the person will no longer be covered at the end of the month but has an eye appointment in six weeks. The person will then need new glasses and would like to pick out the frame, pay for frame and lenses now in spite of the fact that there is no prescription, and submit the claim under the existing vision care plan.

Naturally in all these circumstances you, the health care professional, have to sign the vision care claim form thus attesting to the validity of the claim.

Which brings us to the second ethical factoid, which is: “Holding to a code of ethics sometimes involves confrontation.” You know that anybody who has developed a plan to deceive the insurance company is going to be disruptive if you refuse to aid and abet. You’ll be in the position of having to justify your refusal. Maybe the consumer will even threaten to take his/her business elsewhere. This is particularly problematic if the product has already been made. It’s not so easy to say ‘No’.

That brings us to the consequences of participating in this type of fraud. Here’s an example of what can happen and has happened.

• An optician was found to have padded insurance claims by abusing a ‘special circumstances’ clause in the vision care plan. It turned out that every person who was covered by the local industrial vision care plan fell under ‘special circumstances’ according to the optician.
• The industry investigated, disallowed the optician from servicing employees of the industry and registered a complaint with the optician’s regulatory body.

This might not be considered fraud but it would certainly fall under the category of professional misconduct with all the regulatory penalties that ensue.

If any of the scenarios described above sound familiar to you; if any of your clients have ever made similar requests, you would be participating in fraud.

Read carefully the warning on vision insurance claim forms:
“FRAUD WARNING: Any person who knowingly files a statement of claim containing any misrepresentations or any false, incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties.”

The best ethical factoid is, “Sign your name only to claims that you know to be absolutely true. Your professional future is at stake.”