MedInfo Health Line

How Medicare Special Agents are Going After Doctors

Medicare has hired 400 ex-FBI agents. What could Medicare do with 400 ex-FBI agents, you’re probably wondering. Stage an agent Olympics? Make a James Bond epic? No–Have them chase after doctors!

Medicare has placed these agents in all major cities in the United States, has given them $400 million dollars, badges and guns, and given them the mission of retrieving the money doctors have quote unquote stolen.

These agents have already begun auditing patient charts, looking for fraud. All chart notes must be legible to an agent without any explanation from staff. All labs and correspondence must be initialed and dated before being placed in the chart. Diagnosis coding must reflect absolute accountability to chart notes. An agent needs only to find a mistake; the agent does not have to prove the physician intended fraud. These are all ten thousand dollar fines per occurrence. And these penalties extend to the administrative staff as well as the physicians. The bottom line is that a physician’s reporting of services must match the documentation.

Documentation is not subjective with Medicare. It is strictly color by numbers/stick to the rules/black and white objective. It’s either right or it’s wrong, and if it’s wrong, Medicare intends to raid your coffers. The new guidelines released for implementation beginning January 1, 1998, must be followed to the T.


RESIGN or be FIRED from a Managed Care Organization

Dr Brittain was a general surgeon in the Mountain Physician Med Group, a managed care organization. He developed a large clientele of referring physicians. After about two years, Mountain Physician’s gave Dr Brittain an ultimatum–either resign or you will be fired. If we fire you, we will be obligated to report you to the Physician National Data Bank.

The National Data Bank was formed by congress to force hospitals and others involved in quality of care to report physician discipline, loss of hospital privileges and loss of licensure, so doctors couldn’t go to another state to practice. To be reported would essentially eliminate all future practice by that doctor. Therefore, attorney Galie has termed the National Data Bank a tomb for physicians. An ignominious end to a professional career.

Although managed care organizations may be formed as an Independent Practice Association, or a medical group, they are in the financial arena to reduce costs. In Mountain, California, Mountain Physicians Medical Group had eliminated 200 doctors one year, 20 doctors the next year, and everyone was waiting for the ax to fall the third year. However, they are being very selective.

The ultimatum given, RESIGN or BE FIRED, trades on an important issue. This shows that a managed care organization is using a quality of care issue, when there is none, to eliminate a doctor. You see, if they fired a doctor, he has recourse to the administrative remedies, the courts and all sorts of retribution. Most, however, lose, are reported to the National Data Bank and never seen or heard from again. However, a physician who resigns has done just that–resigned. Hence, he can no longer change his mind. He loses his practice, but he avoids the risk of the National Data Bank. And it all looks voluntary, even if done under the threat of losing one’s professional career and future.


The Health Department Raids

Headlines in the WSJ indicate that the state made a surprise series of raids. No these were not drug dealers, smugglers, rapists, murderers or other felons. These raids were on non-profit and university hospitals. Were they selling organs or body parts? No, they were checking on the hours that the house staff was working. These hospitals had already hired phlebotomists and others to reduce resident’s workload.

These inspectors showed up at the hospital’s doorstep declaring “they would be here 24 hours a day and over the weekend.” They asked the administrators to leave the room as they conducted their interviews. After interviewing first-year residents, they check those facts with the second-year resident and so on to the staff physicians.

Dr Speck, the COO of New York & Presbyterian Hospital, decried the Bell rules, which were being enforced as ridiculous, arbitrary and capricious. He stated the residents have to get the appropriate amount of sleep, but more important, they have to get the proper amount of instruction.

One rule is that residents in a medical ward can’t work more than 24 hours straight.

Dr. LaDue at UCSF, in commenting about the 24-hour shift, stated the traditional 36 hours on and 12 hours off was more in tuned with human circadian rhythm. During the night that the intern or resident is on, he may only get 3 or 4 hours of sleep, but they will be deep sleep when the core body temp is low and thus the sleep is very effective. If the resident goes home after 24 hours, he will be tired at home, may nap or even have a restless sleep, which will not be REM sleep since the core body temp is not down. That evening, the resident will again have a fitful sleep since he won’t be tired, having napped during the day. The possibility of errors is increased the following day when he returns to duty.

As usual, laws are quite insensitive, never physiologic and seldom based on medical evidence. As physicians we should keep our own house in order without having lawmakers always regulating us.


Loss of Hospital Privileges

Last month we told you about two doctors who were targeted for loss of privileges. In each case they eventually won. However, all had fallen out of favor with Hospital A in the past. The attorney fees in one case were well over $50,000. In one case, the loss of income was so great that the doctor could not keep his cash flow going to meet expenses and he had to file a corporate bankruptcy. He lost everything he had accumulated over 15 years of practice, including his retirement plan, but managed to keep his home fully mortgaged and thus of no significant bankruptcy value.

In the latter case, after winning, the hospital merged with another one in the same community. The two hospitals obtained a new license and so all the doctors were told that their privileges at the two hospital would cease as of the effective date of the new license and they would have to apply to the newly licensed merged hospital.

Seven doctors had been suspended over the previous decade from one of the two hospitals, and they were told that their new applications were being reviewed. The other five hundred doctors on the staff got immediate privileges.

Two of the seven doctors obtained immediate legal counsel. The other five said that they would get an attorney if they didn’t make it–How naive. The two with an attorney were given new privileges and the five without an attorney were not. After being suspended (not given privileges) they did obtain attorneys. The same attorneys that helped the two doctors retain their privileges for twenty hours of work or about $6000, told the others they would need $60,000 up front to take the case, and it could easily go to twice that with no guarantees. They were told it was almost impossible to get a hospital to change their mind once they had planted their feet into concrete and the hospitals could spend almost unlimited attorney fees to make sure they would prevail. The attorneys have a saying, you can pay me now or you can pay me later. But if you decide to pay me later it will cost you at least ten times as much.

The attorneys parting advice: Never, ever deal with a hospital, medical board, Medicare, or any agency that gives you privileges without having an attorney who specializes in medical staff privileges.


The Dirty Work of Managed Care

Dr Linda Peeno, a former medical reviewer and medical director for three managed care organizations, testified before the House of Representatives Subcommittee on Health. She stated: “I will begin by making a public confession: In the spring of 1987, as a physician, I caused the death of a man. No one held me accountable for this–for this was a half million-dollar savings to my employer. In fact, this act secured my reputation as a “good” company doctor and insured my advancement in the health care industry. In fact, in a little more than a year I went from making a few hundred dollars a week to an annual six-figure income. In all my medical work, I had one primary duty: to use my medical expertise for the financial benefit of the organization. According to the managed care industry, it is NOT an ethical issue to sacrifice a human being for a “savings.” I was told repeatedly that I WAS NOT DENYING CARE, I WAS ONLY DENYING PAYMENT.”

She concluded her testimony pointing out that every managed care plan establishes the plan as the final authority for determining medical necessity. “What that means is that there is some physician like me NOT practicing or seeing patients, but is sitting behind a desk making decisions completely removed from the consequences of his or her decision who is getting paid to make those decisions for the benefit of a health plan, not the patient. This job is defined by how much they saved the company; by meeting a certain denial quota. This position has no CODE OF ETHICS for it is a hybrid role between executive and physician. This administrative physician receives a lucrative income for adding to the suffering of patients; haunted by the thousands of pieces of paper on which she has written the deadly word: DENIED; and in one case DIED. That is the evidence that managed care is inherently unethical. We need to get that message out to all physicians and patients.”

Dr Peeno presented this message to the national convention of the Association of American Physicians and Surgeons in Raleigh, North Carolina. We enjoyed meeting her and subsequently speaking with her again when she came to Sacramento for the premier of the movie about her story, Damaged Care, shown on Showtime and in some theaters. Linda is someone from the inside of an HMO with the courage to say I made a mistake–I did a terrible wrong by doing what the HMO wanted me to do. Watch for the movie.


Hospital Homicide

Hospitals are doing what we call PEER REVIEW, where doctors reviews each other records to make sure everyone is giving appropriate care. PEER REVIEW works fine much of the time. But in recent years, it has been subject to considerable abuse. Some have estimated that in some hospitals up to 70 percent of the reviews are by hospital doctors who review the private doctors in order to get them off the staff of the hospital. It’s amazing that the reverse never works.

A private doctor was reviewing a hospital doctor’s records that had been selected for review because of some red flag, such as an unexpected death. The private doctor noted that this medical director of a hospital department had misdiagnosed a serious heart failure patient as having pneumonia. It was all quite clear from the history, examination, and x-ray reports.

After making the wrong diagnosis, he then stuck a needle in the chest on the left side to remove what he thought would be pus rather than heart failure fluid. The patient was on life support with the ventilator moving his lungs up and down. To put the needle in one has the patient hold his breath, or if he’s on a machine, you remove him from the machine and breath him manually and hold his breath by holding the bag and doing the tap quickly. This hospital medical director forgot to do this and ripped the lung and the spleen beneath causing prompt death.

The private reviewing doctor noted a discrepancy in the coding of the chart and the records librarian mentioned that the hospital doctor forced her to make this change. She felt guilty about what she considered a cover up. After this was written up, the hospital continued to cover up what would otherwise be considered a felony… So if you’re a favorite of the hospital, killing a patient may be OK. If you’re not a hospital favorite, you may lose your license even if you’re one of 70 percent of such cases with good care.


HMO Satisfaction Rating

HMOs have been very successful in reducing health care costs. This has happened primarily by intimidating doctors to provide less care and reduced hospital charges. The HMOs tell patients when they sign them up that they can get all the consultations and care they’ve been accustomed to. When the doctor puts the breaks on the system because he knows he’ll not survive if he doesn’t, the patients complain. There is a lot of passing the buck.

HMOs will tell their enrollees after a denied service to just have their doctor sign a retroactive authorization. We already know this doesn’t work. Today we found out that neither the employees of HMO nor our managed care organization knew that. Confusion is rampant. But HMOs are able to put a positive spin on a bad image.

Consumer Reports gave an HMO a 61 percent satisfaction index. The HMOs, according to George Anders in the Wall Street Journal, have become very sophisticated in their own polls. They found that telephone polls give higher satisfaction ratings than written polls. Also, new subscribers give a higher performance rating, even before they have any experience with the system. Hence, during the sign up quarter the new subscribers give a much higher rating than during the last quarter when they will be more disgruntled. Thus, the satisfaction index will be up to 50 percent higher in an HMO’s personal poll than in an unbiased poll.

Thus with only a 61 percent favorable rating, the HMO is advertising a 91 percent positive image. Dishonesty is rampant in our health care. Sometimes it’s hard to tell. We must keep on guard less we sit on the keg when the dynamite explodes.

These messages were written in the years as noted and may be somewhat dated at this time. Please consult your physician or other health care provider.