The phenomenon of Fee Splitting, or the unethical and illegal division of fees between physicians and other healthcare providers, represents a significant challenge in professional medical ethics. This practice, often driven by the desire to attract more patients or increase financial gain, carries serious ethical, legal, and social consequences. This paper aims to explore various dimensions of Fee Splitting, beginning with its definition and typologies, followed by an analysis of its implications. It also examines global approaches to address this issue, including stringent regulations in the United States, transparent reporting systems in the United Kingdom, and the use of technology in Singapore. In Iran, despite laws prohibiting this practice, weak enforcement and economic pressures have contributed to its persistence in certain segments of the healthcare system. Insights from successful global experiences suggest that implementing transparent oversight systems, leveraging artificial intelligence to detect violations, and promoting ethical professional practices through education can play a critical role in mitigating Fee Splitting. The paper also presents practical strategies to prevent and combat Fee Splitting in Iran. These strategies include strengthening regulatory frameworks, educating physicians on professional ethics, utilizing advanced technologies to monitor financial transactions, and introducing clear and lawful financial incentives. Furthermore, the importance of fostering cultural change and reshaping public perceptions within the medical community is emphasized. The findings of this study underscore that addressing Fee Splitting as a serious ethical challenge requires a shared commitment from physicians, policymakers, and society at large. By reforming oversight structures, prioritizing education, and employing innovative tools, a more transparent healthcare system can be established, enhancing trust within the medical profession.

Fee splitting, a clear manifestation of physician's breaching patient' s rights, is the breach of the principle known asbona fide with regard to the patient and the dominance of physician's financial interest on facilitation of treatment process. Yet a question is posed: Can physician's abusing patient's trust or lacks of information, whose manifestation can be observed in fee splitting, justify the necessity of criminalizing fee splitting? In fact, the point of argument is to criminalize or decriminalize fee splitting. Some patients have exposed to high cost of treatment without any medical necessity. Accordingly, the authors of this writing try to identify the necessity of providing criminal protection for this group of patients through studying the arguments posed by advocates of fee splitting and those posed by opponents. This writing then deals with constituent elements of fee splitting and studies necessary principles and features to commit this crime from the viewpoint of teachings of medical criminal law.

In spite of basic differences in physician market, we have to consider main derivatives of physician services pricing. Analyzing the marginal cost of generalist and specialist shows that the “fee splitting” occurs when there is a divergence between price and the marginal opportunity cost of specialist. We hope that when the prices of such services are equal with marginal costs, the kickbacks will be vanish. In other words, fee splitting becomes a tool for eroding monopoly power; it provides a channel to transfer some part of specialists’ monopolistic power to generalists.In this study we use three economical theoretic instruments to analyze the fee splitting. First of all, by using the “theory of agency” we can discuss about the physician violations from their tasks as an agent. Afterward we apply theoretical principles of behavioral economics to examine the differences between physicians and other economic factors decision making. Finally we analyze the marginal cost differences between generalists and specialists to clarify the main economic origins of fee splitting.

Background: Fee splitting (FS) is return of a portion of treatment fees for referring patients to practitioners or healthcare centers and is a practice, which is seen, more or less in our medical profession. Although Fee splitting has been noticed and criticized in international publications and medical associations, it seems to be overlooked in our national society of medical practice.Method: Foreign medical literature and attitude of medical societies towards FS as well as legal aspects of this issue were studied. Then the analysis was presented through results and discussion.Results: Reliable medical literature and attitude of most of medical societies are not only in strong opposition to FS but also this issue is considered immoral and illegal in their view. In most of the countries some codified law has been formulated against FS. Some renowned authorities of medical profession have strongly opposed to FS. Also it has been remarkably emphasized that charging patients is permitted only for direct medical services. Although different types of FS are seen in our medical society, unfortunately or national medical societies have taken no practical action in this regard.Conclusion: FS is totally against patients ‘rights and medical profession and leads to destruction of ethical practice of medicine and prevention of scientific-ethical development of medical society. Therefore, medical societies are primarily responsible to take practical measures and provide educational services for medical students and residents.

BACKGROUND: Fee splitting is a process whereby a physician refers a patient to another physician or a healthcare facility and receives a portion of the charge in return. This survey was conducted to study general practitioners’ (GPs) attitudes toward fee splitting as well as the prevalence, causes, and consequences of this process. METHODS: This is a cross-sectional study on 223 general practitioners in 2013. Concerning the causes and consequences of fee splitting, an unpublished qualitative study was conducted by interviewing a number of GPs and specialists and the questionnaire options were the results of the information obtained from this study. RESULTS: Of the total 320 GPs, 247 returned the questionnaires. The response rate was 77. 18%. Of the 247 returned questionnaires, 223 fulfilled the inclusion criteria. Among the participants, 69. 1% considered fee splitting completely wrong and 23. 2% (frequently or rarely) practiced fee splitting. The present study showed that the prevalence of fee splitting among physicians who had positive attitudes toward fee splitting was 4. 63 times higher than those who had negative attitudes. In addition, this study showed that, compared to private hospitals, fee splitting is less practiced in public hospitals. The major cause of fee splitting was found to be unrealistic/unfair tariffs and the main consequence of fee splitting was thought to be an increase in the number of unnecessary patient referrals. DISCUSSION: Fee splitting is an unethical act, contradicts the goals of the medical profession, and undermines patient’ s best interest. In Iran, there is no code of ethics on fee splitting, but in this study, it was found that the majority of GPs considered it unethical. However, among those who had negative attitudes toward fee splitting, there were physicians who did practice fee splitting. The results of the study showed that physicians who had a positive attitude toward fee splitting practiced it more than others. Therefore, if physicians consider fee splitting unethical, its rate will certainly decrease. The study claims that to decrease such practice, the healthcare system has to revise the tariffs.

We investigate the association between managerial overconfidence and audit fees, as well as the effect of a strong audit committee on this relation. Overconfident managers tend to overestimate their ability and the future payouts of projects but underestimate the likelihood and impact of adverse events. Auditors may therefore charge a fee premium to compensate for the additional audit effort due to the increased audit risk. Conversely, overconfident managers may demand less audit services due to either hubris in their companies’ financial reporting or a desire to reduce auditor scrutiny over aggressive accounting. A strong audit committee can alleviate the audit risks associated with managerial overconfidence or prevent overconfident managers from reducing audit services thus mitigating the relation between audit fees and managerial overconfidence. We survey 73 companies in Stock Exchange in the year’ s 1384 to 1393 find that a negative relation is between managerial overconfidence and audit fees. In addition, a strong audit committee also can’ t reduce this negative effect.

In the field of health care and medical practice, gain sharing plans should be carefully examined to be sure they reflect the codes of ethics. Ethical principles involved in gain sharing include informed consent and conflict of interest. Physicians must discharge their responsibilities to patients with loyalty, honesty and good faith, all the while avoiding conflict of interest. Conflict of interest rules usually focus on financial gain. This may raise some important issues, including kickbacks, fee-splitting and self-referral. These practices can potentially distort professional judgment. Some countries have rules of professional conduct governing these issues. In this article, we intend to describe importance of the issues of kickbacks, fee-splitting and self-referral in the field of clinical medicine and discuss some ethical issues that should be considered by physicians.

The amount of audit effort and, consequently, audit fee of companies is affected by the type of Business strategy. A review of the business strategy and its relation to auditors' efforts in the context of Standard No. 11 of the Audit Supervisory Board refers to the need for auditors to have adequate knowledge of the business and industrial environment of the client for the planning of the audit work. In this regard, the main objective of this research is to investigate the relationship between the type of business strategy of the client and the audit fee of the companies. Following the researches of Mills and Snow (1978, 2003), in this research, indicators of capital intensity, renovation of property and equipment, overhead efficiency and financial leverage were used for determining the type of client business strategy (aggressive strategy and defensive strategy). The statistical population of this research is the companies accepted in the Tehran Stock Exchange during the years 1387 to 1394 and the sample size is 680 observations (year-company). The results of the data analysis show that there is a positive (direct) correlation between the client's aggressive strategy and the audit fee. These results also show that the aggressive strategy has a more positive correlation with audit fee compared to the defensive strategy.

Using variables such as client size, complexity, risk, internal auditor, auditor size, and industry, empirical research explains price behaviour of audit fees, and often attributes this pattern to audit fee model. Our study helps to explain why the audit fee model does not fully explain the level of audit fees, because it does not take account of fee stickiness and the influence of previous fees. This paper examines the audit fee stickiness in Iranian firms, using panel data analysis. The sample is comprised of 79 publicly traded firms listed in Tehran Stock Exchange (TSE) using object oriented sampling method. Using data for 1386-1392, we find evidence that audit fees are sticky, i.e. they do not fully adjust to the levels predicted by a standard audit fee model. Audit fees also go up more quickly than they come down. We also find that the difference between upward and downward audit fee adjustments reduces in the second year and when longer periods of time are aggregated. Furthermore the results show that changing auditors has no effect on audit fee stickiness.