How to Exercise Integrity in Medical Billing: Don't Distort Prices, Don't Free-Ride on Other Physicians

This paper proposes that billing gamesmanship occurs when physicians free-ride on the billing practices of other physicians. Gamesmanship is non-universalizable and does not exercise a competitive advantage; consequently, it distorts prices and allocates resources inefficiently. This explains why gamesmanship is wrong. This explanation differs from the recent proposal of Heath (2020. Ethical issues in physician billing under fee-for-service plans. J. Med. Philos. 45(1):86-104) that gamesmanship is wrong because of specific features of health care and of health insurance. These features are aggravating factors but do not explain gamesmanship's primary wrong-making feature, which is to cause diffuse harm not traceable to any particular patient or insurer. This conclusion has important consequences for how medical schools and professional organizations encourage integrity in billing. To avoid free-riding, physicians should ask themselves, "could all physicians bill this way?" and if not, "does the patient benefit from the distinctive service I am providing under this code?" If both answers are "no," physicians should refrain from the billing practice in question.