Consult fraud?

[eimaise]

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I am a third year resident at a large academic medical center working this month on an inpatient consult service. It's been mildly busy, but now it's slowing down a lot and we only have a couple of patient's left on the last (3 to be precise). Yesterday, I felt it was time to sign off on one of these patients and so I diplomatically asked my attending about signing off now since we had nothing left to offer. They replied that the only reason we're following this patient still is so that I will still "have something to do" and not "be bored."

Tell me if I'm wrong, but I am really bothered with this and I feel it is borderline fraudulent to the patient since we are adding NOTHING to the patient's care but we are rounding, writing a note, and billing them every day for no benefit to them.

In addition to this, this particular attending will hold on to patients on our list for 2 to 3 weeks even if we're doing nothing new for them except writing a note that says "continue x plan" the same as the previous 15 days... When I asked this attending why we were doing this since no other consultant I've ever worked with in residency does this, they replied, "we're in a new age of medicine now, and we need to document we're getting enough RVU's... etc.").

I think it's ridiculous and I wanted to hear what others thought. Should I talk to anyone about this?

 

[AdmiralChz]

They were consulted and are seeing the patient, it’s up to them when and if to sign off.

You’re new to the clinical realm (MS-3), not signing off and dropping notes everyday is so much better than the reverse - consultants who see the patient once or twice and stealthily signoff, leaving you to page them endlessly for updated recommendations. You’ll see this, and be very frustrated.

Like SS said above, you’re the student on service - be interested, learn and move on. If you were the fellow you could address this issue, maybe. Definitely not as a student.

 

[AdmiralChz]

Whoops misread the OP, my bad. Advice still stands.

 

[Perrotfish]

So this is, arguably, waste. It is not fraud. Fraud requires a lie. If you bill for services you have not performed it is fraud. If you lie to an insurance company about the criteria used to justify your treatment it is fraud. However if you just do something that's not very useful it's not fraud, as long as you are honest about what you are doing and why you are doing it.

 

[eimaise]

Fraud is a VERY strong word to throw around for a pretty benign sounding issue (consultant who likes to hang onto his consults and not sign off).

My advice would be to just round on your one patient, and move on at the end of the month.

So this is, arguably, waste. It is not fraud. Fraud requires a lie. If you bill for services you have not performed it is fraud. If you lie to an insurance company about the criteria used to justify your treatment it is fraud. However if you just do something that's not very useful it's not fraud, as long as you are honest about what you are doing and why you are doing it.

Thanks for your feedback. I see that fraud was the wrong term to use. I guess I was unclear on my definition. Sorry about that.

You call it benign, but I would still argue that rounding on and charging a patient for a service solely for the reason to "keep the residents occupied" ... etc., is unethical and dishonest to the patient. The initial consult question was answered 7+ days ago and there's no additional issues being tackled by us.

I agree, Perrotfish, that it contributes to waste in the system.

 

[eimaise]

They were consulted and are seeing the patient, it’s up to them when and if to sign off.

You’re new to the clinical realm (MS-3), not signing off and dropping notes everyday is so much better than the reverse - consultants who see the patient once or twice and stealthily signoff, leaving you to page them endlessly for updated recommendations. You’ll see this, and be very frustrated.

Like SS said above, you’re the student on service - be interested, learn and move on. If you were the fellow you could address this issue, maybe. Definitely not as a student.

As you already discovered, I am a PGY-3 and have done numerous consult months previously during resdiency. None of them have done anything like this, which is why it bothers me. I hate the waste in the system. There's no fellows on this service so it's just me and the attending. You might be interested to know that other residents and attendings in the department have noted this issue with this attending but just mutter and complain about it without actually doing anything. Now that I'm working with this person, it's started to bug me more every day.

I too have seen the frustrating reverse issue of having to page the consultant back for advice after they signed off quietly. It's not usually a big deal here though because we have in-house fellows for almost all the specialties so it's pretty easy to just page or Cortext them.

 

[Donald Juan]

I agree with above. Drop it. It's not fraud, it's just being a little wasteful. You can learn from this how you don't want to practice.

 

[Bobblehead]

Other possibilities include this attending having been burned by signing off and then something happening on a prior patient. Stuff like that can stay with you for a while. Or this specific attending isn't being assigned enough workload to generate his RVU requirements or is not meeting them for some reason is in danger of losing his position, not making his paycheck etc. Or he feels he should give you something to do because the residents always complain there's nothing to do on this service and the service is in danger of losing its residents entirely.

You are on a subspecialty consult service. That means by definition you know less the consultant about the field you're being consulted on. When it comes time and he says "I'm being careful because the patient is unstable, unusual, I have a bad feeling etc. based on my judgement and experience" vs. you reporting "He's being wasteful because I as a non-subspecialist 3rd year trainee don't see anything being done, we should report him to the insurerer/Medicare" what do you think the outcome will be?

Also as you point out others have done nothing. So either your judgment of what's ethical/wasteful differs from everyone else's in terms of reporting or there are other reasons that you are not aware of.

 

[rokshana]

As you already discovered, I am a PGY-3 and have done numerous consult months previously during resdiency. None of them have done anything like this, which is why it bothers me. I hate the waste in the system. There's no fellows on this service so it's just me and the attending. You might be interested to know that other residents and attendings in the department have noted this issue with this attending but just mutter and complain about it without actually doing anything. Now that I'm working with this person, it's started to bug me more every day.

I too have seen the frustrating reverse issue of having to page the consultant back for advice after they signed off quietly. It's not usually a big deal here though because we have in-house fellows for almost all the specialties so it's pretty easy to just page or Cortext them.

so suck it up for the next 7 months and when you are an attending, don't do it...but now? as a pgy-3? why would you want to rock that boat and possibly have it blowback on you?

 

[NotAProgDirector]

I hear your frustration. There is a huge spectrum of consults. In one of our community sites that refers / transfers to us, it's routine to see any patient admitted for some other problem but who is on levothyroxine for chronic hypothyroidism get an endo consult, which then says to check the TSH and continue the current dose (and I might add that's usually bad advice, because a TSH in acute illness is often inaccurate). But it always happens. And the consult note seems very templated. It's pure waste, for sure. Perhaps fraud if you could prove that all the docs colluded and agreed to just get consults for each specialty to help boost RVU's (which sounds like is part of the issue you're facing). It makes me ill. I expect that this small community hospital might feel like it has to do this to generate enough revenue / business to keep the doors open.

I agree that your best option is probably to just plug ahead, and recognize this is not ideal care. if you actually recorded your faculty saying that he/she was doing it solely to boost their RVU's, then that is true fraud. You could file a whistleblower report -- you could make lots of money if the hospital is penalized. If everyone else acts differently (i.e. it's a person issue, and not a culture issue), you could bring this to one of your chief resident's or PD's attention. If this was happening at my institution, we would clamp down on it -- mainly to protect against the fraud issue. Or you could do nothing.

 

[rokshana]

I hear your frustration. There is a huge spectrum of consults. In one of our community sites that refers / transfers to us, it's routine to see any patient admitted for some other problem but who is on levothyroxine for chronic hypothyroidism get an endo consult, which then says to check the TSH and continue the current dose (and I might add that's usually bad advice, because a TSH in acute illness is often inaccurate). But it always happens. And the consult note seems very templated. It's pure waste, for sure. Perhaps fraud if you could prove that all the docs colluded and agreed to just get consults for each specialty to help boost RVU's (which sounds like is part of the issue you're facing). It makes me ill. I expect that this small community hospital might feel like it has to do this to generate enough revenue / business to keep the doors open.

I agree that your best option is probably to just plug ahead, and recognize this is not ideal care. if you actually recorded your faculty saying that he/she was doing it solely to boost their RVU's, then that is true fraud. You could file a whistleblower report -- you could make lots of money if the hospital is penalized. If everyone else acts differently (i.e. it's a person issue, and not a culture issue), you could bring this to one of your chief resident's or PD's attention. If this was happening at my institution, we would clamp down on it -- mainly to protect against the fraud issue. Or you could do nothing.

i would hope no endo worth their salt would recommend getting a TSH while inpt...usually what happens is that a TSH gets included in the AM labs that are ordered and its off...then endo is consulted and we say continue current levothyroxine and repeat TSH in 6- 8 week once pt has returned to their baseline. As a fellow i would roll my eyes and smack my head at these.

 

[eimaise]

So make a mental note of it and when it’s your turn to be in practice, don’t do it.

It’s certainly not worth raising a stink over, especially when the counter argument is exceptionally easy to predict (ie attending claiming he’s providing continuity of care/access to specialists, and claiming the lazy resident just doesn’t want to do the work).

I agree with above. Drop it. It's not fraud, it's just being a little wasteful. You can learn from this how you don't want to practice.

so suck it up for the next 7 months and when you are an attending, don't do it...but now? as a pgy-3? why would you want to rock that boat and possibly have it blowback on you?

Duly noted. Thanks. I just wanted some thoughts. Wasn't expecting such strong feelings from people on this issue.

 

[DoubleBogey]

i would hope no endo worth their salt would recommend getting a TSH while inpt...usually what happens is that a TSH gets included in the AM labs that are ordered and its off...then endo is consulted and we say continue current levothyroxine and repeat TSH in 6- 8 week once pt has returned to their baseline. As a fellow i would roll my eyes and smack my head at these.

And after fellowship you will gladly perform the consult with a smile

 

[ophthapp1]

Duly noted. Thanks. I just wanted some thoughts. Wasn't expecting such strong feelings from people on this issue.

never underestimate sdn for strong feelings on any issue. instead of a nuanced conversation about the question at hand, it seems like many posters are simply interrogated regarding their motive for asking the question in the first place. And then most advice boils down to "bend over and take it for 6 more months!"

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[evilbooyaa]

Duly noted. Thanks. I just wanted some thoughts. Wasn't expecting such strong feelings from people on this issue.

Whenever you bring up strong terms that have significant legal ramifications like 'fraud' or 'malpractice' or 'assault' in a forum of physicians without demonstrating a situation that is either of those things, you will generally got strong pushback regarding your statements.

If you had come in with a "hey, there's this attending doing things I think are wasteful, what do you guys think about this situation" it'd have lead to softer responses

Consult fraud is not seeing a patient, or not doing a procedure, and billing for it. This is, IMO, nowhere near the definition of fraud.

 

[michaelrack]

And after fellowship you will gladly perform the consult with a smile

It depends on the employment situation.

 

[PlutoBoy]

I think that the management of long standing hypothyroidism is arguably within the scope of practice of IM.

 

[VA Hopeful Dr]

I think that the management of long standing hypothyroidism is arguably within the scope of practice of IM.

Much of what hospitalists consult for is within the scope of IM. Its then an issue of either not enough time or wanting someone else to share the liability.

 

[JustPlainBill]

PGY3? Dude (or dudette as the case may be) -- just chill and graduate -- use this time to pick that attending's brain re: billing, etc. In a few short months, you'll be punted out into the world on your own and you'll wish you had someone to bounce ideas/questions off of in the safe environment of residency.....relax....

 

[rokshana]

And after fellowship you will gladly perform the consult with a smile

I most definitely do!

 

[Apollyon]

Duly noted. Thanks. I just wanted some thoughts. Wasn't expecting such strong feelings from people on this issue.

You title your thread with "fraud" (which is criminal). However, you did say that maybe that was too strong, but, in your OP, you state the attending was making sure "we're getting enough RVUs". Inadvertently, you may have actually found the fraud. You're surprised at "strong feelings"? That is rather dichotomous.

 

[eimaise]

You title your thread with "fraud" (which is criminal). However, you did say that maybe that was too strong, but, in your OP, you state the attending was making sure "we're getting enough RVUs". Inadvertently, you may have actually found the fraud. You're surprised at "strong feelings"? That is rather dichotomous.

What I mean is that I was surprised at strong feelings at how everyone is telling me to "chill, relax, calm down, drop it, back off etc." when I am bringing an issue up that seemed important to me. I'm not stressed about it.

I clearly see now that I was wrong about it not being fraud. I still think what she is doing is inappropriate. I'm actually kind of surprised more of you all don't agree with me that it's not fair to the patient to continue seeing them (and billing them daily) on a consult for up to 1 to 2 weeks after any other rational attending would have signed off on them. I think only like one person up there felt this was a problem.

PGY3? Dude (or dudette as the case may be) -- just chill and graduate -- use this time to pick that attending's brain re: billing, etc. In a few short months, you'll be punted out into the world on your own and you'll wish you had someone to bounce ideas/questions off of in the safe environment of residency.....relax....

I am completely relaxed. I don't know what gave you the idea I was stressed about this. I'm not waving red flags or speaking with departments heads about this. I said originally I was bothered by it, which is true.

What I am also concerned about is waste in the system and using up resources inappropriately. Even though it's not fraud, it's still not the optimal situation and I think it could be improved. Fair?

 

[eimaise]

I agree that your best option is probably to just plug ahead, and recognize this is not ideal care. if you actually recorded your faculty saying that he/she was doing it solely to boost their RVU's, then that is true fraud. .

That's interesting. Thanks for the clarification. They did say something along those lines, like "we need to see all the patients every day and write notes on them so we can generate more RVU's, etc." I just didn't record it.

Perhaps it's a function of this service being really slow right now. On most consult services I've been apart of, the lists will be 10 to 20 patients daily and we will round, answer questions in our notes, and sign off, or just follow peripherally. Here, we will get consulted, round, write a note, and then write the same dang note every day for weeks with like 1 to 2 small changes. Even after their consult-specific issues have resolved, we continue following them just to "keep the resident's busy."

Whatever guys. I'm not trying to turn this into a huge issue. I was mistaken about the fraud (can I change the title of the forum so people relax a bit?) but it still bothers me.

 

[NotAProgDirector]

Much of what hospitalists consult for is within the scope of IM. Its then an issue of either not enough time or wanting someone else to share the liability.

Or a matter of padding useless consults for more RVU's.

That's interesting. Thanks for the clarification. They did say something along those lines, like "we need to see all the patients every day and write notes on them so we can generate more RVU's, etc." I just didn't record it.

Just to be clear, I don't recommend recording them. If you do, check the laws in your state.

Perhaps it's a function of this service being really slow right now. On most consult services I've been apart of, the lists will be 10 to 20 patients daily and we will round, answer questions in our notes, and sign off, or just follow peripherally. Here, we will get consulted, round, write a note, and then write the same dang note every day for weeks with like 1 to 2 small changes. Even after their consult-specific issues have resolved, we continue following them just to "keep the resident's busy."

Whatever guys. I'm not trying to turn this into a huge issue. I was mistaken about the fraud (can I change the title of the forum so people relax a bit?) but it still bothers me.

It should bother you. It's wrong.

 

[gutonc]

One thing that hasn't been mentioned yet (and that you, as a resident, probably have no clue about), but many Medicare/Medicaid admits are paid under what's called a DRG where there's essentially a lump sum payment for the hospital course. In those cases, the patient isn't getting charged more every time your attending writes a note, he's just carving out a bigger piece of the pie for himself.

I'm not going to pretend it's not sketchy as hell. But your patients may not be getting as hosed as you think they are. (But somebody is.)

 

[Raryn]

One thing that hasn't been mentioned yet (and that you, as a resident, probably have no clue about), but many Medicare/Medicaid admits are paid under what's called a DRG where there's essentially a lump sum payment for the hospital course. In those cases, the patient isn't getting charged more every time your attending writes a note, he's just carving out a bigger piece of the pie for himself.

I'm not going to pretend it's not sketchy as hell. But your patients may not be getting as hosed as you think they are. (But somebody is.)

Hmm. That's news to me. I was under the impression that the DRG was used for hospital billing, but the physician billing was separate from that.

That is, the DRG covers the nurses/meds/janitors/whatever (hence why doing *less* labs/imaging/etc is actually better $$$ for the hospital for a medicare patient), but the physicians still bill their H&P/follow up codes over and on top of that. I've had attendings more or less state that they're billing per day, versus after X days the hospital is basically losing money on the case. Maybe that billing is just used to split up a static pie, but it didn't seem that way to me.

 

[NotAProgDirector]

Hmm. That's news to me. I was under the impression that the DRG was used for hospital billing, but the physician billing was separate from that.

That is, the DRG covers the nurses/meds/janitors/whatever (hence why doing *less* labs/imaging/etc is actually better $$$ for the hospital for a medicare patient), but the physicians still bill their H&P/follow up codes over and on top of that. I've had attendings more or less state that they're billing per day, versus after X days the hospital is basically losing money on the case. Maybe that billing is just used to split up a static pie, but it didn't seem that way to me.

This is correct. DRG is how the hospital gets paid. When I see a patient in the hospital, I submit a billing code for my professional time also.

 

[Nephro critical care]

Hmm. That's news to me. I was under the impression that the DRG was used for hospital billing, but the physician billing was separate from that.

That is, the DRG covers the nurses/meds/janitors/whatever (hence why doing *less* labs/imaging/etc is actually better $$$ for the hospital for a medicare patient), but the physicians still bill their H&P/follow up codes over and on top of that. I've had attendings more or less state that they're billing per day, versus after X days the hospital is basically losing money on the case. Maybe that billing is just used to split up a static pie, but it didn't seem that way to me.

Agree with Raryn. Physician professional time billing is not part of the hospital DRG. At least not yet. The day it will be hospitals are going to clamp down on unnecessary and even necessary consults as it will eat into the hospital’s DRG pie. Right now they don’t care. All they care about is extra coding by physicians to show higher acquity and increase the value of their DRG , decreasing LOS and being efficient at discharge without readmission.

 

[gutonc]

I was under the impression that for hospital employed docs it was.

I retract my previous statement.

 

[Raryn]

I was under the impression that for hospital employed docs it was.

I retract my previous statement.

The hospital may do the billing for the hospital employed docs, but their codes are still paid for by Medicare. Depending on the employment contract I suppose it may or may not matter.

 

[Perrotfish]

I clearly see now that I was wrong about it not being fraud. I still think what she is doing is inappropriate. I'm actually kind of surprised more of you all don't agree with me that it's not fair to the patient to continue seeing them (and billing them daily) on a consult for up to 1 to 2 weeks after any other rational attending would have signed off on them. I think only like one person up there felt this was a problem.

Its a reasonable concern, though I'm not sure I would say no 'rational' attending would have signed off. I'm in the military system, where there are no RVUs and where consult services are frequently slow, and I have seen many attendings continue to consult on patients weeks after they could have signed off to generate teaching opportunities, even though their is no possible benefit to them for doing so.

 

[eimaise]

Its a reasonable concern, though I'm not sure I would say no 'rational' attending would have signed off. I'm in the military system, where there are no RVUs and where consult services are frequently slow, and I have seen many attendings continue to consult on patients weeks after they could have signed off to generate teaching opportunities, even though their is no possible benefit to them for doing so.

Interesting to hear. True, saying "no rational attending" was a bit over the top. But with no possible benefit to the patient, and yet they are still rounding and billing for it... it just doesn't sit right with me. I would be upset if I was a patient and would be questioning why they were rounding on me with nothing to add?

 

[hello1234!]

Maybe your attending doesn’t trust that Hospitalist and would rather follow pt for the pts benefit, you never know ...

 

[HomeSkool]

I think it's ridiculous and I wanted to hear what others thought. Should I talk to anyone about this?

I understand why you're upset and I don't like the attending doing this, either, but I have one question for you: is this the hill you want to die on?

Pick your battles wisely.

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