CRNA Whistleblower retaliation for hiring AA's in Northern Michigan

[siednarb]

News out of Michigan where apparently 2 CRNA's whistleblew regarding billing practices which started after an AA was hired into the practice.

Traverse City anesthesia practice to pay $600K for false Medicare claims

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[Mikkel]

Petty, vindictive.

Sounds about right.

 

[ERRES2288]

Wish I was surprised, wonder what part of medical direction they weren’t meeting or if even true.

 

[AdmiralChz]

News out of Michigan where apparently 2 CRNA's whistleblew regarding billing practices which started after an AA was hired into the practice.

Traverse City anesthesia practice to pay $600K for false Medicare claims

I saw this as well, but the article itself says the CRNAs were let go and then they filed the whistleblower complaint. Unless you have inside information this doesn’t appear to be “revenge” for hiring AAs, it makes much more sense for them to do it as retaliation for being fired.

 

[coffeebythelake]

Scott Stone CRNA and Bethany McKinley CRNA

 

[deleted126335]

Michigan Doctors Must Pay Out in Anesthesiology Whistleblower Case

Two CRNAs will split a $120,000 reward after filing an anesthesiology whistleblower claim alleging that a Michigan anesthesiology group violated TEFRA and c

www.mahanyertl.com

Plaintiff's attorney's website and version of this case.

 

[nimbus]

The group has almost 60 anesthesiologists, CRNAs, and AAs. The fine is around 10k/person or 20k/doctor pretax. They probably took the least expensive course of action.

 

[deleted126335]

The group has almost 60 anesthesiologists, CRNAs, and AAs. The fine is less than 10k/person. They probably took the least expensive course of action.

The settlement (not fine) and legal fees were borne by the owners exclusively. Not all the employees collectively.

 

[nimbus]

The settlement (not fine) and legal fees were borne by the owners exclusively. Not all the employees collectively.

No doubt it’s an unwanted expense but still not crippling. And it may eventually affect employees. If they dragged it out it could have been much more expensive.

 

[deleted126335]

No doubt it’s an unwanted expense but still not crippling. And it may eventually affect employees. If they dragged it out it could have been much more expensive.

No doubt about that. Settling a lawsuit is a business decision. Especially when your opponent is the government of the US

 

[siednarb]

here is the original complaint for those interested in reading (it's 90 pages)

 

[2.0%]

It looks like TAA dodged a bullet with that settlement agreement... The outlined events of the complaint.pdf were fairly damning. The CRNAs should have filed formal reports sooner, but they were ultimately right to do so based off the allegations and evidence they provided. I know that is going to be an unpopular opinion here, but in the interest of patient safety we should all try to condone these shady practices.

 

[nimbus]

Do practices with 1:4 supervision stagger morning starts to comply with TEFRA?

 

[BLADEMDA]

Do practices with 1:4 supervision stagger morning starts to comply with TEFRA?

The same way Donald Trump spins the facts. I think he claims a weight of 225 pounds for example.

I’m not saying “spinning” is illegal but one can certainly question its truthfulness.

 

[nimbus]

The same way Donald Trump spins the facts. I think he claims a weight of 225 pounds for example.

I’m not saying “spinning” is illegal but one can certainly question its truthfulness.

So the stuff described in the complaint is standard?

 

[2.0%]

So the stuff described in the complaint is standard?

Some of the complaints for sure. I would argue that providing regional anesthetic then immediately leaving the patient alone without monitoring and documenting they were left in the care of a CRNA who was both unaware of this and busy providing anesthesia to another patient could be problematic though.

 

[ERRES2288]

I’ve always wondered how it is possible to be present for induction in 3-4 first start rooms

 

[Arch Guillotti]

I’ve always wondered how it is possible to be present for induction in 3-4 first start rooms

Cases start early or late.
Staggered cases.
Both rooms of a surgeon that "flips".
Sedation cases.
Cases that have a spinal put in ahead of time.
Endoscopy.
A partner that starts it for you.
etc.

 

[AdmiralChz]

I’ve always wondered how it is possible to be present for induction in 3-4 first start rooms

Very few have induction at the exact same instant: some go back early, late, require some positioning, waiting for stuff from surgeon etc.. or it’s regional case.

Actually our hospital system gives little rewards/kudos to staff who manage to get in the room early. This helps. Our bigger cases (vascular, neuro) actually all start 30 minutes later again taking pressure off.

 

[dannyboy1]

This is stupid on the part of the CRNA’s. When they apply for another job a quick google search of their names will send their resumes into the trash, regardless of how desperate the practice is.....

 

[Mman]

So the stuff described in the complaint is standard?

I couldn't even read through that whole thing but it was like a greatest hits of what not to do. The worst of all to me was people repeatedly pulling closed charts after the fact to document stuff they didn't actually do or weren't present for. I mean that is pretty damning. That's not just the oh you forgot to sign the chart sort of thing.

 

[jwk]

I saw this as well, but the article itself says the CRNAs were let go and then they filed the whistleblower complaint. Unless you have inside information this doesn’t appear to be “revenge” for hiring AAs, it makes much more sense for them to do it as retaliation for being fired.

Perhaps the hiring of AAs was the triggering event? I don't know - the complaint is mind-numbing to read. I agree with MMan that it's a blueprint of how not to handle billing issues. I will say that AAs have been practicing in Michigan under delegatory authority allowed by their Medical Practice Act for at least 30 years. They are not a new phenomenon in Michigan by any means. Hiring AAs into a toxic CRNA-dominated practice is never an easy process. That being said, it's been done quite successfully many many times over the years.

For those that have ACT practices billing medical direction - be aware that CRNAs are actively encouraged by their "professional organizations" to act as whistleblowers, not as some noble altruistic act, but as a way to encourage CRNA-only practices, and to limit by any means possible the expansion of AA practice anywhere they can. AAs do indeed have to be medically directed. For those practices that try to "get by", be aware that your actions are being noticed, and as in this case from Michigan, noted and documented in quite detailed fashion.

We have a very large, by the book, ACT practice. It's perfectly manageable, but not necessarily always easy. We go to pains to make sure our actual day to day practices as well as our documentation are correct. Nobody can sign in for anybody else for anything - the EMR requires ID and passwords, and everything is automatically time/date recorded. Our MDs satisfy all 7 steps of TEFRA. An anesthesiologist is present for every induction, period. We don't induce the patient until they're in the room - we wait. The surgeons don't whine because they know this is how we practice. And really - how long does "induction" last? Push the drugs, airway in, sign, and go. Two minutes? Three? It's just not that limiting.

Remember that in a true ACT practice, an anesthesiologist is actively involved in the care of each and every patient. Isn't that the goal?

 

[anbuitachi]

what about present for epidurals in a busy L&D at night? do you stand there and watch the crna put in every epidural overnight?

 

[AdmiralChz]

what about present for epidurals in a busy L&D at night? do you stand there and watch the crna put in every epidural overnight?

Different rules. Only "immediately available" much like a MAC GI case, and since it's not an "anesthetic" per se it doesn't count towards your case numbers. To me and regulators, this probably means you are in the building. For others, maybe within a 30 minute response period.

 

[jwk]

what about present for epidurals in a busy L&D at night? do you stand there and watch the crna put in every epidural overnight?

We have the busiest OB practice in the US and every single epidural is placed by an anesthesiologist. Ditto for every spinal, every block, every central line.

 

[anbuitachi]

We have the busiest OB practice in the US and every single epidural is placed by an anesthesiologist. Ditto for every spinal, every block, every central line.

so what does the crna do at 3am? or are you md only

 

[jwk]

so what does the crna do at 3am? or are you md only

CAAs and CRNAs Sections, occasional OR cases. We keep docs and anesthetists in-house 24/7/365. Remember that placement of labor epidurals while medically directing is a specific exception to the rule.

 

[Arch Guillotti]

Different rules. Only "immediately available" much like a MAC GI case, and since it's not an "anesthetic" per se it doesn't count towards your case numbers.

???

 

[deleted171991]

I’ve always wondered how it is possible to be present for induction in 3-4 first start rooms

In multiple universes. In every universe, the doc is in a different room. Easy!

 

[chocomorsel]

We have the busiest OB practice in the US and every single epidural is placed by an anesthesiologist. Ditto for every spinal, every block, every central line.

Oh God. Kill me now!! Quickly please. This sounds absolutely horrible. I hope your docs are only doing 12 hour shifts.

 

[ProRealDoc]

We have the busiest OB practice in the US and every single epidural is placed by an anesthesiologist. Ditto for every spinal, every block, every central line.

Why don't you help them?

 

[jwk]

Why don't you help them?

It's their rules. I don't make them. The widely-held CRNA belief that the anesthesiologist drinks coffee and does crosswords in the lounge all day is far from reality in our practice. Everybody stays busy.

 

[siednarb]

Our practice is exactly like jwk's - every induction we are present, every epidural, nerve block, spinal - we do them - no exception. The CRNA's attend the epidurals with us and do the charting and bolus after we have placed the epidurals etc....

 

[PieOHmy]

It's their rules. I don't make them. The widely-held CRNA belief that the anesthesiologist drinks coffee and does crosswords in the lounge all day is far from reality in our practice. Everybody stays busy.

With electronic charting, they have figured out a way to keep us busy clicking boxes all day long.

 

[deleted126335]

With electronic charting, they have figured out a way to keep us busy clicking boxes all day long.

They have also figured out a way to know exactly how much time we spend clicking boxes. How many seconds per page read. Which pages you could have read but didn't. Soon they will know exactly how much time we spend everywhere.

Our system is considering getting custom internal use only linked to the internal network iPhones that will track every movement down to the square yard within the hospital. So that case that you pushed drugs on at 9:00 am but didn't physically visit the OR for another 2-3 hours will be discoverable. Didn't visit the PACU during patient X's entire stay?...Discoverable. Just waiting for the filming of every operation.

 

[Ronin786]

Oh God. Kill me now!! Quickly please. This sounds absolutely horrible. I hope your docs are only doing 12 hour shifts.

Really? Patient prepped and draped, CRNA already consented, all you do is walk in put the epidural and bounce.

CRNA does the charting and manages the usual hypotension. Sounds like an excellent use of my skills.

 

[IMGASMD]

Just waiting for the filming of every operation.

Know of a hospital already do this. “To improve turn over time....”.

Future is already here.

 

[PieOHmy]

THey should have NEVER settled this case.
Someone has to get a handle on the mid level provider thing
AA legislation should be on every states agenda.
CRNAs will never be f***in happy!!!

 

[deleted941485]

Really? Patient prepped and draped, CRNA already consented, all you do is walk in put the epidural and bounce.

CRNA does the charting and manages the usual hypotension. Sounds like an excellent use of my skills.

Honestly I haven’t figured out why they haven’t come up with an automated system for charting and administering drugs. I mean if you could get that down groups could maybe reduce staff needs. I guess if you stagger the cases right you can be there for emergence and extubation. Watch 2 or 3 rooms from a single monitor.

Ofcourse the details of that are rough and regulatory stuff would be a problem.

 

[Mikkel]

Honestly I haven’t figured out why they haven’t come up with an automated system for charting and administering drugs. I mean if you could get that down groups could maybe reduce staff needs. I guess if you stagger the cases right you can be there for emergence and extubation. Watch 2 or 3 rooms from a single monitor.

Ofcourse the details of that are rough and regulatory stuff would be a problem.

Here's the best idea: run the OR like an ICU, have an ICU RN 1:1 with the patient (cheaper than CRNA). Slow the pace down so that the RN doesn't have to do anything without you present. Monitor remotely via CCTV and vitals monitors.

If the pace is right, I could see myself running 4-8 of these rooms at a time. The key is the deceased efficiency and slower time scale.

Not saying I want to, but in a disaster situation with limited anesthesia personnel, this is feasible.

 

[deleted941485]

Here's the best idea: run the OR like an ICU, have an ICU RN 1:1 with the patient (cheaper than CRNA). Slow the pace down so that the RN doesn't have to do anything without you present. Monitor remotely via CCTV and vitals monitors.

If the pace is right, I could see myself running 4-8 of these rooms at a time. The key is the deceased efficiency and slower time scale.

Not saying I want to, but in a disaster situation with limited anesthesia personnel, this is feasible.

Yeah I’m thinking you could run rooms with less qualified personnel at minimum. I mean you’d probs still be in the OR but more kind of managing from a computer screen using speacilized software for this sort of thing. Who knows...just spit balling here.

 

[IMGASMD]

Here's the best idea: run the OR like an ICU, have an ICU RN 1:1 with the patient (cheaper than CRNA). Slow the pace down so that the RN doesn't have to do anything without you present. Monitor remotely via CCTV and vitals monitors.

If the pace is right, I could see myself running 4-8 of these rooms at a time. The key is the deceased efficiency and slower time scale.

Not saying I want to, but in a disaster situation with limited anesthesia personnel, this is feasible.

Now from crna or mid level perspective.... “They” (MD/DO) don’t want to go into OR anymore. We have the numbers, we have the training.
Game over.

I don’t know if we can pull ahead when some believe the best thing is MD only practice at one extreme. The other extreme is eliminating CRNA and just use RN to run cases. 8 cases with RNs? You just need a difficult spinal and a lost IV/airway to do you in.....

*i admit, I have no solution.

 

[deleted941485]

Now from crna or mid level perspective.... “They” (MD/DO) don’t want to go into OR anymore. We have the numbers, we have the training.
Game over.

I don’t know if we can pull ahead when some believe the best thing is MD only practice at one extreme. The other extreme is eliminating CRNA and just use RN to run cases. 8 cases with RNs? You just need a difficult spinal and a lost IV/airway to do you in.....

*i admit, I have no solution.

You’d have to risk stratify and get like your ASA 1-2s low risk for complications intra op and do them in one section of the OR where you’ll be close by. Again probably not a complete answer. Maybe higher risk should be 1:2 or just 1:1.

 

[Mikkel]

Now from crna or mid level perspective.... “They” (MD/DO) don’t want to go into OR anymore. We have the numbers, we have the training.
Game over.

I don’t know if we can pull ahead when some believe the best thing is MD only practice at one extreme. The other extreme is eliminating CRNA and just use RN to run cases. 8 cases with RNs? You just need a difficult spinal and a lost IV/airway to do you in.....

*i admit, I have no solution.

I wrote a long reply, then realized the current way of doing things isn't that bad to justify the huge changes necessary to make a philosophical/structural change.

 

[PieOHmy]

Technology, Technology technology..... I still cant believe that in the past few ORs ive been to i still have to struggle to find out whats going on in my room. When i mean struggle i mean its more than a click on my phone away.
I should be carrying an ipad to see exactly whats going on at any second. Id spend my money there rather than spending most of the day clicking boxes to document **** for people who have no idea what my work flow is about.

Technology will do the crna movement in..

 

[aneftp]

This is one of the reasons my former practice did non medically directed. Sure. It meant the practice probably “lost” 2 million or more a year. Which is a ton. But the 3 majority original owners who founded the practice in 2001 decided it wasn’t worth the risk because we couldn’t meet the 7 criteria for medical direction.

practice was 70% plus Medicare. 2.5 plus million in subsidy from hospital. Small practice where MDs did 50% own cases. We actually didn’t Cover 4 rooms often. It was usually half docs in room solo. And docs outside covering 3 rooms usually. And the owners still didn’t think we could meet all 7 criteria of medical direction with covering 3 rooms.

Of course a major amc took over in 2016 and claimed we were losing revenue because of this. I’m sure they are billing differently now. Who knows. Not my problem.

I also worked as 1099 contractor and refused to check box medical direction in general cases I wasn’t present for induction because that’s a critical element for medical direction.

when I worked for federal/state/academics. Where I’m usually 1:2. Occasionally 1:3. We are always medical direction. Always present for induction. Very strict at federal and state facilities I have worked with. They go by the letter of the medical direction rules and don’t mess around.

 

[Arch Guillotti]

They have also figured out a way to know exactly how much time we spend clicking boxes. How many seconds per page read. Which pages you could have read but didn't. Soon they will know exactly how much time we spend everywhere.

Our system is considering getting custom internal use only linked to the internal network iPhones that will track every movement down to the square yard within the hospital. So that case that you pushed drugs on at 9:00 am but didn't physically visit the OR for another 2-3 hours will be discoverable. Didn't visit the PACU during patient X's entire stay?...Discoverable. Just waiting for the filming of every operation.

Who or what is driving this?

 

[Arch Guillotti]

Nobody can sign in for anybody else for anything - the EMR requires ID and passwords, and everything is automatically time/date recorded.

So what do you do when the anesthesiologist is unavailable for a period of time? Dealing with disaster elsewhere, in ICU starting a central line, struggling with a pediatric IV on induction, etc. Do you just wait around?

 

[nimbus]

So what do you do when the anesthesiologist is unavailable for a period of time? Dealing with disaster elsewhere, in ICU starting a central line, struggling with a pediatric IV on induction, etc. Do you just wait around?

Bill as supervision, not medical direction?

 

[Arch Guillotti]

Bill as supervision, not medical direction?

His practice is 100% medical direction.