Justinian C. Lane, Esq.
Let Justice Be Done, Though the Heavens May Fall
JCL.jpg

Justinian Lane's Blog

Justinian's Blog

Defensive Medicine – At a Minimum, It’s a Breach of Contract

Defensive medicine occurs when a doctor orders a test he or she doesn’t think is medically necessary, but orders it solely to protect him or herself from a medical malpractice lawsuit.  Read the following excerpt from the Blue Cross Blue Shield of Michigan contract with participating doctors:

Medical Necessity is determined by Physicians1. For purposes of payment by BCBSM, Medical Necessity or Medically Necessary means a determination by Physicians for BCBSM based upon criteria and guidelines developed by Physicians2 for BCBSM, or, in the absence of such criteria and guidelines, based upon physician review, in accordance with accepted medical standards and practices, that the service:

is accepted as necessary and appropriate for the patient’s condition and is not mainly for the convenience of the member or Physician; and in the case of diagnostic testing, the tests are essential to and are used in the diagnosis and/or management of the patient’s condition. (Emphasis added.)

In other words, a doctor who runs a test he or she doesn’t believe is “essential” is breaching his or her contract with BCBS.  Yet somehow, instead of being angry at doctors who breach contracts and commit insurance fraud, we blame lawyers.

Here’s hoping the new debates over healthcare reform raise the public’s awareness over the fact that it’s unethical and often illegal for a doctor to practice “defensive medicine.”