Ethical Dilemma in Billing

[Barry1960]

I have an ethical dilemma that I need help with.

I am an Endocrinologist, who lives in a neighboring state to my sister and mother. I am DPoA for medical affairs for my 90 year old mother with moderate Alzheimer’s Disease. My sister, who my mother lives with, is DPoA for finances and pays the bills. My mother has both Medicare part A and B and Federal Blue Cross Insurance. She fell, fracturing her pelvis through the right acetabulum (and ilium), which was repaired surgically. She is non-weight bearing for 12 weeks and as result is in a nursing/rehab facility, rather than my sister’s home until she can walk again.

The issue: My sister shows me bills to Blue Cross from a Physical Medicine physician assistant at the rehab facility for 4 visits per week for my mother’s first 7 weeks, while she was on SNF status, with copays of $25/visit (in 2023) and $30/visit (for 2024). There were no charges for visits starting the day after SNF was stopped and we began nursing home self pay.

My mother was stable the entire time (expect for minimally symptomatic COVID) and in my opinion, did not need 4 provider visits per week X 7 weeks. After a visit with the nursing home director, I was told the PA would call me to talk about it. Instead I was called by her supervisory physician, who tells me the PA is off due to a death in the family. He does not acknowledge anything wrong with the billing but agrees to contact his team and refund my mother’s co-pays.

Am I making a mountain out of a molehill? Do I have a responsibility to take this matter further to protect the public from what is at a minimum over-charging and possibly might even be outright fraud. If so, should I go to the facility director, the state medical society, Medicare, Blue Cross or some combination of the above?

The screen shots below are text messages from my phone that conclude my interaction with the supervising Physiatrist.

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[Momentum70]

Something doesn't seem right to me either here. Ive done SNF and IPR and the medicare limit is 2 visits per week snf and daily in IPR unless something has changed that I dont know about. At first I thought maybe they were acting as the primary and not consultant, but your text exchange clarifies they are not primary. I am really curious what these notes look like that they wrote 4 days a week on a stable SNF patient as I would suspect copy paste daily and doing nothing. No idea wtf a PA consultant would being doing that many days a week as consultant. Your sister should be able to request all medical records from your mom's visit.

 

[RangerBob]

I thought the Medicare limit was 3 visits per week in a SNF. I see the mention of max of two per week above. Perhaps someone who's currently doing SNF work can verify what the limit is. I work on acute inpatient rehab, where our minimum is 3 visits per week and max is daily.

If 4 visits/week is allowed, then it may or may not have been appropriate for the PM&R team to see that often. There's a lot of work behind the scenes a good PM&R physician is doing (communicating with RNs, therapists, running team meetings, helping with dispo, etc.). If a patient is truly stable and there's nothing changing and the notes are literally copy/pasted, then it'd be hard to justify seeing a patient that much. Ultimately Medicare/insurance asks us to self-regulate and see patients as often as we feel is necessary.

Reviewing the medical records is certainly a good start. As would talking with the medical director/facility director.

I also don't know the rules of midlevel providers rounding at SNFs, but a certain number of acute inpatient rehab visits have to be by the physician (I don't know the exact number as we don't use PA's/NP's). We can't rely solely on PA's to round here. I question if this applies to SNFs as well?

Some groups rely on PAs/NPs to bill like crazy. And some unscrupulous docs will take advantage of the system. This might include billing physician-level charges when only the PA saw the patient.

Still, even if 4 visits/week are allowed by insurance, I agree something seems off here. The fact the supervising physician plans to refund all the copays you made whilst not saying the charges were/weren't appropriate sticks out a bit to me. If I have a patient/family member asking me about the appropriateness of the charges I submitted, I would explain why they were appropriate (because I don't see/bill inappropriately). The fact the supervising physician didn't do that, but says they'll refund all the copays, is odd. With an emphasis on the fact they're refunding all the copays. Are they refunding the insurance payments too? That's the bulk of the earnings they get. So it strikes me as odd that they're not commenting on the validity/appropriateness of their charges and it a makes me wonder if refunding your financial obligation is to keep you happy/quiet.

So I agree, something seems a bit off here.

 

[PMR2008]

Something is very off here. I have done SNF work with and without APPs for 12 years now. I don’t like to use the word fraud but this seems excessive in many ways. I would investigate futher and ask for notes. In all my years of practice I have seen only a handful of patients more than 2/week.

 

[sloh]

Ya I’ll second this. I’ve never seen patients more than twice weekly. The patient would need to be decompensating almost acutely to warrant more than 2 visits/week—in which case they likely should have been transferred to the ER/hospital/inpatient.

 

[sloh]

That said even when patients are seen twice weekly the notes don’t need to change all that much bc there’s a lot of management and coordination going on behind the scenes

 

[Iamnew2]

I have an ethical dilemma that I need help with.

I am an Endocrinologist, who lives in a neighboring state to my sister and mother. I am DPoA for medical affairs for my 90 year old mother with moderate Alzheimer’s Disease. My sister, who my mother lives with, is DPoA for finances and pays the bills. My mother has both Medicare part A and B and Federal Blue Cross Insurance. She fell, fracturing her pelvis through the right acetabulum (and ilium), which was repaired surgically. She is non-weight bearing for 12 weeks and as result is in a nursing/rehab facility, rather than my sister’s home until she can walk again.

The issue: My sister shows me bills to Blue Cross from a Physical Medicine physician assistant at the rehab facility for 4 visits per week for my mother’s first 7 weeks, while she was on SNF status, with copays of $25/visit (in 2023) and $30/visit (for 2024). There were no charges for visits starting the day after SNF was stopped and we began nursing home self pay.

My mother was stable the entire time (expect for minimally symptomatic COVID) and in my opinion, did not need 4 provider visits per week X 7 weeks. After a visit with the nursing home director, I was told the PA would call me to talk about it. Instead I was called by her supervisory physician, who tells me the PA is off due to a death in the family. He does not acknowledge anything wrong with the billing but agrees to contact his team and refund my mother’s co-pays.

Am I making a mountain out of a molehill? Do I have a responsibility to take this matter further to protect the public from what is at a minimum over-charging and possibly might even be outright fraud. If so, should I go to the facility director, the state medical society, Medicare, Blue Cross or some combination of the above?

The screen shots below are text messages from my phone that conclude my interaction with the supervising Physiatrist.

Doesn't seem legit. Shouldn't be more than 2-3 times per week at most. There is a lot of billing fraud out there. My husband - who spent about 13 days in an LTACH for vent weaning after pneumonia and was relatively stable - had charges of $184,000 + billed to the insurance company. In the same manner a lot of billing is fraudulent. I would inquire how or why the billing is so excessive from the PA.

 

[Barry1960]

Thank you everyone for taking the time answer. I appreciate the confirmation by you, who are in this field, that my suspicions of over-billing seem correct. I did request the notes and found extensive copy and pasting of the same note (including some obvious errors), such as in the HPI, "the patient fell last night," in all 20+ notes. The notes are 98% the same text, the exception is in the section called, "Interim History," where sometimes the the text is same and sometimes different. But the assessment and plan is exactly the same in every single note.

I have waited for my mother to return home to make sure there could be no retribution against her. Now that she is home, I will be writing a letter to the administration of the Augusta Center for Health and Rehabilitation, where she was, so they can know the type of people practicing under their roof. In addition I will write to my mother's insurances of Medicare and Federal Blue Cross as they may want to look into this and request some money back, as I did. I have decided not to take this to the Maine State Medical Board.