CHARLESTON, W.Va. -- Health insurance companies often negotiate agreements with physicians to reduce costs in exchange for recommending those physicians to their clients.


But in some cases, physicians turn down health insurance from patients hurt in car wrecks because they can get more money from the company that insured the person who caused the wreck.

Physicians sometimes ask patients injured by third parties to sign "letters of protection," or LOPs, before treating them, especially if they have no health insurance or financial assets to pay medical bills.

LOPs guarantee that physicians will get paid their fees if the patient wins legal action against those who injured them.

Sometimes, physicians even recommend specific lawyers to their patients.

Earlier this month, on Nov. 9, the West Virginia Board of Medicine ruled such arrangements could violate medical ethics.

"An LOP is not an ethically prohibited contractual agreement," according to the Nov. 9 public policy statement.

But LOPs generally guarantee "the full payment of the physician's fees, irrespective of any negotiated discount and/or reduced reimbursement rates with health insurers," the board stated.

Those agreements typically "provide the physician higher reimbursement than if he/she submitted the fees [directly] to the health insurer..."

"Requiring an LOP from an established patient who has health insurance previously accepted by the practitioner may place the physician's financial interests ahead of the patient's welfare."

The Medical Board's statement urges physicians always try to bill a patient's insurance company first.

"Only upon rejection by the insurer of the claim will the LOP go into effect," the board stated.

The Medical Board issued its statement two months after it signed a consent order with H.S. Ramesh, a Charleston physician also known as Dr. Holenarsipur Seshaiah Setty Ramesha.

Under the Sept. 9 consent order, Ramesh agreed to pay a $1,000 fine for requiring "Patient 1," the unidentified victim of a car accident, to sign an LOP before treating her for injuries from that accident.

The accident victim had been one of Ramesh's patients since March 2002, six years before her accident in early 2008.

At the time, Patient 1's lawyer, Harry Deitzler, told Remesh he would pay all medical bills not covered by her health insurance with CIGNA, if her legal claim against the person who caused the accident was successful.

In a July 17, 2008, letter to the Medical Board responding to Patient 1's complaint, Ramesh stated Medicare, Medicaid and private insurers "pay only a fraction of my usual and customary charges," the Medical Board consent order stated.

"Had Patient 1 agreed to an LOP," the order continues, "Dr. Ramesh would have been reimbursed at a higher rate for his services than had he accepted Patient 1's policy of insurance."

Ramesh also told Patient 1 she should hire William H. Harding as her lawyer, not Deitzler. Ramesh then handed Patient 1 one of Harding's business cards.

The West Virginia State Bar's Office of Disciplinary Counsel also opened an investigation of Harding's relationship with Ramesh, back in April 2008.

Andrea J. Hinerman, senior disciplinary counsel for the State Bar, said in a Sept. 29 letter to Deitzler that the "complaint remains under investigation at this time."

"Physicians are free to choose whom they will serve," according to American Medical Association guidelines cited by the West Virginia Board of Medicine in its Nov. 9 public policy statement.

But physicians also "have an obligation to support continuity of care for their patients," the AMA added.