A family physician is reviewing a patient’s lab test results, and one of the tests shows an abnormal result that is of potential concern. The physician can’t recall requesting that test, given the patient’s health status. In reviewing the medical record and original test requisition, the physician observes the test was not included there. What could account for the discrepancy and what should the physician do with this information?
In such situations, a physician may suspect a patient fraudulently created or altered a lab test requisition. Such a suspicion is heightened when, for example, the test is not within the scope of the physician’s practice and is not something they would typically request. While an administrative error at the lab may occur, it’s also possible that the patient had faked or altered the requisition.
While there are many reasons why a patient would change a lab test requisition, doing so has consequences for both the patient and physician. Knowing how to handle such a situation can help ensure patient safety and reduce medico-legal risk for the physician.
Diagnostic test continuum is disrupted, but not nullified
Many medical regulatory authorities (Colleges) have policies that set their expectations of physicians for following up on lab test requests and results. The ordering physician is, in most instances, responsible for following up on test results. When a requisition is fraudulently created or altered, step 1 of the diagnostic test continuum, namely the “test ordered” step is omitted. Nevertheless, the test is performed, and the result is generated and returned to the physician. The physician then reviews the results, at which point they may discover the apparent discrepancy.
Steps for physicians to handle falsified test requisitions
Here are steps to consider if you receive the result of a lab test you did not request.
1. Verification and documentation
- Cross-check the test results report with the original test requisition, the patient’s medical history and previous tests.
- Document in the patient’s medical record the test result and the discrepancy, including any evidence of falsification of the requisition.
2. Communication
- Notify the patient of the test result.
- It is appropriate to ask the patient if they know anything about the requisition and why the test in question was administered. Take a non-judgmental approach, avoiding accusatory language. The goal is to determine whether the patient falsified the requisition, and if so, why.
- If the patient indicates they did alter the document, continue to engage in a calm, open conversation to understand the reasons why the patient felt the need to make the alteration.
- Depending on the reasons given, inform the patient that such activity constitutes healthcare fraud and is illegal.
- You may wish to refer to the Choosing Wisely Canada initiative, which provides a list of recommendations concerning unnecessary or overused tests and treatments. Explain that some tests and treatments may expose patients to harm, and unnecessary ones consume valuable healthcare resources.
- Document the key points of the discussion in the medical record.
3. Assessment and follow up
- Use your clinical judgment to assess the test result and continue to provide appropriate follow-up care.
- If the test result is abnormal, pay attention to it even though you did not order the test. Advise the patient of the result and any needed or recommended follow-up care. If the test conducted falls outside your scope of practice or knowledge, consider advising the patient of this and suggest a referral.
- If the result is normal, this should reassure the patient and allay their concerns.
- Document the discussion and care plan.
- This type of activity may create tension in the doctor-patient relationship and constitute a breakdown in trust. Depending on the circumstances, you may wish to end the relationship, as discussed below.
Fostering patient-centered care
A patient may choose to falsify a test requisition owing to feelings of distrust or information the patient had obtained from other sources (e.g. online, friends, another health provider). Patients may be less likely to engage in such activity—and more likely to adhere to advice for investigative or treatment plans— when their physician involves the patient in decisions about their care.
To help nurture patient-centered care, physicians should encourage open and honest communication, and if a patient has a special request for care should consider accommodating it if feasible. This includes understanding the reasons behind a special request, and assessing whether it could be reasonably accommodated in your setting.
Ending the doctor-patient relationship
If the trust in the doctor-patient relationship has been broken, patients and physicians alike may decide to end that relationship.
Patients are free to leave their current physician’s practice at any time and seek care from another provider. Physicians, meanwhile, may end a doctor-patient relationship provided certain conditions are met. Before doing so, ensure you understand and comply with your College’s requirements, which include ensuring the patient has access to urgent or emergent care, and has been provided reasonable notice to find another healthcare provider.
Reporting to authorities
While there is no general duty for physicians to report patients suspected of having committed a crime to police, legislation in some jurisdictions permit or require reporting of healthcare fraud – which includes falsification of requisitions and other documents. Contact the CMPA for individual advice.
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