Would you report this?

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Let's say that this is a hypothetical situation where an attending is performing surgery in the OR, then returning to clinic to sign off on patient notes (seen and discussed with resident) at the end of the day when the patients have left. For clarity, when she comes down from the OR, she takes the paper charts sitting in the completed bin and signs them, then bills them to medicare under her own name. Is this fraud?

It depends. Postoperative care within 90 days after surgery is part of the global surgery fee, and not billed separately. So it's not strictly necessary for the attending to see the patient, as long as they are "adequately" supervising the resident who sees them. If the attending didn't see the patient, or saw them without the resident, it should be documented "discussed with resident" +/- "seen separately" if appropriate. But as there's no difference in payment in the postoperative period, no one gets particularly worked up about it unless the institution is already under scrutiny for fraud.

If the patient is >1day preop, >90 days postop, or a consult or new patient, the attending must see the patient in order to bill.

That's my understanding, but someone please correct me if I'm wrong. It's been a little while since I dealt with academic documentation and billing.

My understanding is that it is fraudulent but common for attendings to sign notes for billing on patients they did not actually examine themselves (because they were in the OR, or because they came in and were dispo'd overnight). Not sure who you would even report it to, but I am certain you would cause a lot of trouble for your program.

Originally Posted by dpmd

My understanding is that it is fraudulent but common for attendings to sign notes for billing on patients they did not actually examine themselves (because they were in the OR, or because they came in and were dispo'd overnight). Not sure who you would even report it to, but I am certain you would cause a lot of trouble for your program.

I am all for ethics and "doing the right thing." At the same time, it seems like a terrible idea to contemplate reporting it. Definitely not worth the risk/consequences of the can of worms that you will be opening...

As others have noted, CMS/insurance fraud is a major issue for residency programs.

In addition to the post operative code 99024, an E/M codes of 99201 and 99211 do not require physician presence. If you are in a program which has a primary care exception, codes 99201-99203, 99211-99213 also do not require attending presence. Are you absolutely sure that the attending was not coding one of these?

Here are the regulations from CMS: http://www.cms.gov/Outreach-and-Educ...gresfctsht.pdf

Unless you're sure it wasn't one of these, it might be better to stay out of it.

Don't report it unless you feel like the patients were somehow in danger. It may or may not be kosher (technically) but doing something about it is a good way to get your own head put on the chopping block.

Originally Posted by Getgo123

Let's say that this is a hypothetical situation where an attending is performing surgery in the OR, then returning to clinic to sign off on patient notes (seen and discussed with resident) at the end of the day when the patients have left. For clarity, when she comes down from the OR, she takes the paper charts sitting in the completed bin and signs them, then bills them to medicare under her own name. Is this fraud?

You're loosing sight of the forest for the trees my friend...

Do yourself a favor and don't report anything. Good luck with your training. Worry about all the medicare/medicaid rule contorting when you're out in private practice and can see it all with a more level head and a pinch of experience/insight into the maddening fed reimbursement game.

For god's sake, don't rat on your attending.

It is Medicare fraud for a physician (or anyone else, for that matter) to bill for work they did not do.

If the attending reviews charts at the end of the day, and the bill goes out with the resident's billing number, that's perfectly kosher. Some insurance carriers will pay for resident care. Some will not.

If the attending puts their own name on the bill, that's fraud. It's fraud even if there is no charge attached to the visit (i.e. the 90 day globals). Kinda funny that you can be fined for submitting bills with no charges on them.

The Primary Care exception codes are much more complicated, and clearly don't apply to the situation described above. In a nutshell, if a physician is supervising no more than 4 residents, and doing nothing else at the same time, then visits of level 1 - 3 do not need face-to-face time by the attending physician -- review of the case during or immediately after the visit is sufficient. In any case, it won't apply at all to the case above.

I would note that, should you report this, you MIGHT be able to collect on a very hefty whistleblower fee. Usually the fines for this sort of thing run into the millions, as technically you can be fined $10K for EACH event (although it's never really that much). A whistleblower gets 10-15% if I remember correctly.

I'm sorry but I highly recommend you NOT report this. Although it may technically not be the right thing, it is a sure way to bring unwanted drama in your life. Don't ever bite the hand that feeds you unless you want to be thrown out in the wild. In that case, I hope you have teeth and claws!

Seriously though, if this is something you feel strongly about, at least approach the attending first and see what they say.

It's also possible that hospital regulations require that the attending sign off on the charts, even if it is billed under the resident.

Unless you're sure that a) the attending is signing that they have in fact seen the patient, and not just discussed the case with the resident, and b) it's being billed as if the attending saw the patient, you really shouldn't report it.

And even if both those things are happening, it would be better to approach the attending in question and ask something general like, "what's the right way to bill a visit if the patient was only seen by the resident?" Followed up by, "What's the penalty if it's done incorrectly?" This would get them thinking about the legality of what they're doing without ever even mentioning the specific situation, and possibly they'll go fix it on their own and not do it again.

Or if it's rampant in your department, you could ask your PD to invite the coding and billing folks to give a presentation to the "residents" on appropriate billing practices, at a time when the attendings are also present.

There are a hundred more effective and circumspect ways to handle this situation other than simply reporting it to Medicare. Most of which will reflect well on you, in addition to avoiding retaliation and fixing the problem

Originally Posted by aProgDirector

It is Medicare fraud for a physician (or anyone else, for that matter) to bill for work they did not do.

If the attending reviews charts at the end of the day, and the bill goes out with the resident's billing number, that's perfectly kosher. Some insurance carriers will pay for resident care. Some will not.

If the attending puts their own name on the bill, that's fraud. It's fraud even if there is no charge attached to the visit (i.e. the 90 day globals). Kinda funny that you can be fined for submitting bills with no charges on them.

The Primary Care exception codes are much more complicated, and clearly don't apply to the situation described above. In a nutshell, if a physician is supervising no more than 4 residents, and doing nothing else at the same time, then visits of level 1 - 3 do not need face-to-face time by the attending physician -- review of the case during or immediately after the visit is sufficient. In any case, it won't apply at all to the case above.

I would note that, should you report this, you MIGHT be able to collect on a very hefty whistleblower fee. Usually the fines for this sort of thing run into the millions, as technically you can be fined $10K for EACH event (although it's never really that much). A whistleblower gets 10-15% if I remember correctly.

You remember correctly and this is 100% on the mark. There have been several hospitals that made the news for medicare fraud. One the hospital ( big university) admitted responsibility, got a discount and paid up. The nearby community hospital didn't and paid dearly.

Never, ever blow the whistle from a position of weakness. As a resident you are weak and the institution is powerful. If you think it is a real problem, then keep very good notes, never on your person, and never at work. Keep them in a safe place. Lab notebooks with numbered pages are a good record, prosecutors love them as they are hard to alter without detection. Then document what you see, keep your mouth shut and wait until you are no longer under the thumb of the institution, and they can do you no harm. Be squeaky clean yourself and do not participate in Medicare fraud, yourself as they will hang you out to dry, if they can.

Once you complete the program, talk to a competent attorney. The law you need is the Federal False Claims Act, which dates back to the reconstruction era when the feds were being sold bad meat. You and your attorney can decide if you have a good case, and if so, draft a complaint and file what is known as a Qui Tam action on behalf of the government. The complaint is sealed and turned over to the U.S. Attorney who then has the option of pursuing the claim or not. If he decides to pursue the government takes over from there and you turn over your stuff wait and if the government collects you get your cut.

If the US Atty declines to run with it, and you and your attorney think you have a case and big enough return, then you can run with it and collect a far larger percentage if you recover government money.

If you do this while a resident you're likely to need to find a new profession. If you do this after residency as an attending, you are likely to be much more (but not completely) immune. Remember, there is a tremendous good ole boy network, you'll be outside of the miscreant's network, but they too have enemies, and as long as you can steer clear of your now former institution by all means have at 'em, as long as you are sure you can prove your story.

At one institution, interns and PGY2 were doing chest taps and belly taps solo and later the attendings came by and signed "present and actively participated in..." and billed Medicare. This one got dinged $54M, the feds offered to settle for $24M and the hospital declined. The final bill was $63M. It ain't chump change, and 10% of $63M will buy a couple of extra bottles of wine, but do this while you're working there, and it'll be a long and thirsty wait. And if you lose, you are toast and you'll never work in the field again.