Dirty Little Diagnosis?

New

York gynecologist Niels Lauersen is a Park Avenue infertility expert and a best-selling author with a high-wattage clientele. He hobnobs with socialites and celebrities--many of whom swear they would be childless but for his treatment. And he has been dubbed the "dyno gyno" by no less than Geraldo Rivera, whose wife was a patient. But last week Lauersen could be found in a distinctly unglamorous locale: Manhattan federal court, where he faces more than a decade of prison time.

Lauersen is being charged with insurance fraud. Prosecutors say he gave couples infertility treatments, like in vitro fertilization, generally not covered by health insurance, and submitted claim forms saying he was treating insured conditions like ovarian cysts. His case is attracting widespread attention both because it is highly unusual for such a prominent doctor to be charged with fraud and because of the impact a conviction could have on the medical profession.

That doctors regularly fudge on health-insurance forms is one of the dirty little secrets of American medicine. Go in for a checkup not covered by your HMO, and your doctor may gin up a covered condition to make the visit reimbursable. It's also true of more serious ailments; a recent study suggested that more than 50% of doctors were willing to falsify bills in those cases.

The medical establishment may wink at false claims, but the insurance industry is less amused: it says about 10% of all money spent on health care last year, or $100 billion, was lost to fraud. The cost gets passed on to other consumers, the industry says, in higher premiums. The end result of the false claims submitted by some financially strapped people, says Kathleen Fyffe of the Health Insurance Association of America, is that other financially strapped people cannot afford insurance.

The government is not about to start second-guessing every internist who insists a cough sounded nasty. But Lauersen, 60, seems to present an extreme case. Prosecutors say he sent out falsified bills and created fictitious office notes, some prepared long after patient visits and then backdated. And the dollar amounts he is accused of defrauding are large: $4 million over the past 10 years.

Lauersen's lawyer argued last week that what he did was treat "real sick people" and that the case comes down to paperwork. His defenders deny he committed fraud, or say it would have been justified if he did. People suffering from infertility--as many as one-sixth of all couples--have long criticized insurance companies for refusing to cover the costly treatment required. If Lauersen's billing practices meant poor couples were able to start a family, his backers say, it's not much of a crime.

Insurers and doctors are watching Lauersen's case closely. A conviction would "put a damper on other doctors who do this," says Dr. Herbert Rakatansky of the American Medical Association. That could help solve the insurance companies' problem. Or it might create new ones. Patients may demand that insurers rewrite the rules so many doctors now feel a need to break.