Physical Presence; you mean like I have to be there?

[evilbooyaa]

My example was a patient coming from 50 miles away on public transport.

We are the only specialty in all of medicine that continually argues about how half (or 3/4, depending on who you ask) of the field is money grubbing people because of X, Y, Z ways that the half of the field does that. Derm doesn't do that, ortho doesn't do that, Rads, anesthesia, even med-onc don't do that. It's really annoying. We're arguing to get paid less.

I really, really wish we didn't continually try to tear ourselves down.

---

Members don't see this ad.

 

[OTN]

My example was a patient coming from 50 miles away on public transport.

We are the only specialty in all of medicine that continually argues about how half (or 3/4, depending on who you ask) of the field is money grubbing people because of X, Y, Z ways that the half of the field does that. Derm doesn't do that, ortho doesn't do that, Rads, anesthesia, even med-onc don't do that. It's really annoying. We're arguing to get paid less.

I really, really wish we didn't continually try to tear ourselves down.

Thank you, thank you, THANK YOU for posting this. I cannot understand why we radoncs constantly are doing this to each other.

 

[deleted18755]

My example was a patient coming from 50 miles away on public transport.

We are the only specialty in all of medicine that continually argues about how half (or 3/4, depending on who you ask) of the field is money grubbing people because of X, Y, Z ways that the half of the field does that. Derm doesn't do that, ortho doesn't do that, Rads, anesthesia, even med-onc don't do that. It's really annoying. We're arguing to get paid less.

I really, really wish we didn't continually try to tear ourselves down.

This is very true and I always thought it was an Internet thing but I've seen more than a few instances in the real world where a radiation oncologist has publically belittled or basically called out his colleague (in one case literally his own practice partner!) for something minor and that at worst cost the system less than one drops worth of a fancy new systemic agent. Basically everybody in the medical community has long thought that radiation oncologists are underworked and overpaid and we all go into the field for the lifestyle ... rather than trying to help correct the misconception why on earth do so many actually actively perpetuate it (while every other field just keeps chugging along?)

 

[Gfunk6]

Basically everybody in the medical community has long thought that radiation oncologists are underworked and overpaid and we all go into the field for the lifestyle ... rather than trying to help correct the misconception why on earth do so many actually actively perpetuate it (while every other field just keeps chugging along?)

I think there a couple of reasons that RO is an outlier this way among medical specialties:

1. Very robust culture of peer review. Our practice chart rounds are highly aggressive and outside non-RO MDs who observe sometimes view it as “bullying.” I view it as an opportunity for self-improvement and self-reflection,but whatever.

2. ASTRO has been absolutely spineless and self-serving when it comes to consensus guidelines. Most recommendations basically say, “do whatever you want.” However, a lot of us think we know better and have strong opinions about it.

3. ROs are joined by the hip to their treatment machines. These are capital intensive and tends to anchor people to one region. This may encourage territoriality.

 

[medgator]

I think there a couple of reasons that RO is an outlier this way among medical specialties:

1. Very robust culture of peer review. Our practice chart rounds are highly aggressive and outside non-RO MDs who observe sometimes view it as “bullying.” I view it as an opportunity for self-improvement and self-reflection,but whatever.

2. ASTRO has been absolutely spineless and self-serving when it comes to consensus guidelines. Most recommendations basically say, “do whatever you want.” However, a lot of us think we know better and have strong opinions about it.

3. ROs are joined by the hip to their treatment machines. These are capital intensive and tends to anchor people to one region. This may encourage territoriality.

If anything, that would encourage overtreatment if you have any technical exposure, rather than undertreatment IMO in regards to what oldking is saying

 

[MegaVoltagePhoton]

I believe in hypofractionation, and even I agree that we're a little too hard on ourselves sometimes. I think it cuts both ways though, as some of the anti-hypofrac people accuse the other side of essentially being irresponsible by exposing patients to toxicity, which I also think is not fair as the data do support its use as long as the counseling is appropriate.

 

[Burt Radnolds]

.

 

[medgator]

What is everyone's thoughts regarding physical presence to approve a plan? This issue came up in our practice, and I think it is totally kosher to approve a plan at home, since there is no patient present, hence no "interruptible" event to assist with, as per Medicare guidelines, since no treatment is being administered, but compliance thinks we have to be in the building to do anything.

 

[Gfunk6]

Agree, approving a plan can be done anywhere, even on the beach. Supervising during treatment is the key.

 

[BobbyHeenan]

What is everyone's thoughts regarding physical presence to approve a plan? This issue came up in our practice, and I think it is totally kosher to approve a plan at home, since there is no patient present, hence no "interruptible" event to assist with, as per Medicare guidelines, since no treatment is being administered, but compliance thinks we have to be in the building to do anything.

I often remote in to review plans on nights and weekends. It's not uncommon for me to sign a plan on a Sat/Sunday, and I bill the plan on the day I sign it, so I do have Medicare billed plans on weekends.

Where we are strict is for treatments - always on hospital campus.

 

[CyberKnife19]

Sorry for the nearly 4 year bump, but any update on this since COVID may have changed the calculus? My rough understanding is that a Radiation Oncologist doesn't have to be present if hospital-based, but does have to be present if it is a free-standing center.

Thank you.

 

[medgator]

Sorry for the nearly 4 year bump, but any update on this since COVID may have changed the calculus? My rough understanding is that a Radiation Oncologist doesn't have to be present if hospital-based, but does have to be present if it is a free-standing center.

Thank you.

How do you define "present"?

Hint: telesupervision "waiver" during the covid19 pandemic that keeps getting extended

 

[deleted1111261]

Sorry for the nearly 4 year bump, but any update on this since COVID may have changed the calculus? My rough understanding is that a Radiation Oncologist doesn't have to be present if hospital-based, but does have to be present if it is a free-standing center.

Thank you.

That’s my interpretation. But ACR / Apex seem to call for it. Not sure how they check that.

 

[Burt Radnolds]

That’s my interpretation. But ACR / Apex seem to call for it. Not sure how they check that.

They don't. In the end, they just want your money.

 

[anotherhopeful]

And a NP/APN can fill this supervisory role AFAIK

 

[deleted1111261]

And a NP/APN can fill this supervisory role AFAIK

They can “if privileged”. When we explored, we had not found a place that has privileged an APP for this and the education / mechanism required to make this kosher. Do you know anyone who has done this ?

 

[anotherhopeful]

I don't. But we are looking into this right now as we have a separate site that needs supervision but not enough volume where another MD makes sense. It seems this is all very vague, perhaps by design. To me, if I had to choose, I'd rather have a NP on site than 'virtual' off site MD supervision as my main concerns are when patients have issues with radiation toxicity. In reality, I will probably hedge and have both with virtual MD supervision but still have a NP on site. Perhaps that way privileging would be less of a concern. All dependent on if virtual supervision gets extended I suppose

 

[dieABRdie]

I think having an NP/PA see patients for radiation toxicity issues is fine, if they also have virtual access to an MD for back up. But having an APP supervise IGRT and patient set up issues seems crazy to me.

I imagine how I would feel if I was a therapist with years of experience and here comes an NP who got his degree online is now responsible for telling me how to set up a patient.

I asked our therapists, many who have over a decade of experience, how they would feel. They said "mutiny." lol

All I would need is a nurse willing to stand there with a tablet and facetime. There are very few things we do with our hands. Most things we can handle as long as we can see.

 

[Mandelin Rain]

I think having an NP/PA see patients for radiation toxicity issues is fine, if they also have virtual access to an MD for back up. But having an APP supervise IGRT and patient set up issues seems crazy to me.

I imagine how I would feel if I was a therapist with years of experience and here comes an NP who got his degree online is now responsible for telling me how to set up a patient.

I asked our therapists, many who have over a decade of experience, how they would feel. They said "mutiny." lol

All I would need is a nurse willing to stand there with a tablet and facetime. There are very few things we do with our hands. Most things we can handle as long as we can see.

Here's the training you give the therapist and NP.

1. If something doesn't look right, call me.
2. If you can't get a hold of me for whatever reason, hold the treatment for the day and ask the patient to come back tomorrow.

I don't think anyone is asking NP to make complex treatment adjustments on the fly.

 

[TheWallnerus]

Here's the training you give the therapist and NP.

1. If something doesn't look right, call me.
2. If you can't get a hold of me for whatever reason, hold the treatment for the day and ask the patient to come back tomorrow.

I don't think anyone is asking NP to make complex treatment adjustments on the fly.

Exactly!

 

[deleted1116990]

And a NP/APN can fill this supervisory role AFAIK

I don't think anyone is asking NP to make complex treatment adjustments on the fly.

Hospital admin to Mandelin Rain: Hold my beer.

I had a phone interview with a hospital recently. They were offering a large amount of vacation time. Enough to tempt me to call about this place I probably otherwise wouldn't be too excited about. I inquired how they intended to cover this as it was a single physician center. I was informed they had an NP that would cover while I was gone. Presumably for weeks at a time on another continent. The manager became annoyed when I asked the follow-up questions anybody who cared would ask after hearing this, and I was not invited for an on site interview.

Unreal.

 

[temujim]

Hospital admin to Mandelin Rain: Hold my beer.

I had a phone interview with a hospital recently. They were offering a large amount of vacation time. Enough to tempt me to call about this place I probably otherwise wouldn't be too excited about. I inquired how they intended to cover this as it was a single physician center. I was informed they had an NP that would cover while I was gone. Presumably for weeks at a time on another continent. The manager became annoyed when I asked the follow-up questions anybody who cared would ask after hearing this, and I was not invited for an on site interview.

Unreal.

And they would sell you out in a second. When the RT or dosi or physics you pissed off (because they suck -- and there's always one) report you CMS hoping to get a reward. Admin would be say "yah dunno what moonbeams was doing there. That guy is the radiation billing/regulatory expert."

 

[deleted1116990]

And they would sell you out in a second. When the RT or dosi or physics you pissed off (because they suck -- and there's always one) report you CMS hoping to get a reward. Admin would be say "yah dunno what moonbeams was doing there. That guy is the radiation billing/regulatory expert."

Correct.

Whoever takes that job is an idiot. One of two things will happen. Either the hospital will not honor the double digit weeks of vacation promised and say tough sue us or they will let you go and the NP will cover, disaster will ensue leaving you with the best case of having to constantly clean up on treatment messes or worst case explain to auditors and attorneys why you thought it was appropriate to have an NP cover patients while you were in France and somehow an SBRT spine got put on the schedule as a non-SBRT treatment and she lined up the target to the cord because "I know where the spine is!"

 

[medgator]

Cases are still settling... Pretty miniscule amount here though

University Of Maryland Shore Regional Health Agrees to Pay $296,870 to Settle Federal False Claims Act Allegations of Billing for Unsupervised Radiation Therapy and Diagnostic Services

The University of Maryland Shore Regional Health in Easton, Maryland (“Shore Health”), has agreed to pay the United States $296,870 to resolve allegations that it violated the federal False Claims Act by submitting false claims to the United States for radiation therapy and diagnostic services...

www.justice.gov

Whistleblower Nets $51,952 in Settlement with University of Maryland Shore Regional Health

The University of Maryland Shore Regional Health will pay $296,870 to settle allegations that it violated the False Claims Act.

whistleblowersblog.org

 

[RickyScott]

Nuisance settlement for an entity the size of maryland.So the whistle blower got 50k-taxes for something that is no longer prohibited? Good luck finding employment.

 

[medgator]

Nuisance settlement for an entity the size of maryland.So the whistle blower got 50k-taxes for something that is no longer prohibited? Good luck finding employment.

Agree. If you are going to blow the whistle, stab your friend in the back, burn some real bridges etc., Do it for real money.

I'm guessing he was smart enough to find employment before he embarked on this, but who knows

 

[RickyScott]

Agree. If you are doing to blow the whistle, stab your friend in the back, burn some real bridges etc., Do it for real money.

I'm guessing he was smart enough to find employment before he embarked on this, but who knows

Maybe, he went to a Ron D seminar and was convinced that billions were at stake?

 

[TheWallnerus]

Cases are still settling... Pretty miniscule amount here though

University Of Maryland Shore Regional Health Agrees to Pay $296,870 to Settle Federal False Claims Act Allegations of Billing for Unsupervised Radiation Therapy and Diagnostic Services

The University of Maryland Shore Regional Health in Easton, Maryland (“Shore Health”), has agreed to pay the United States $296,870 to resolve allegations that it violated the federal False Claims Act by submitting false claims to the United States for radiation therapy and diagnostic services...

www.justice.gov

Whistleblower Nets $51,952 in Settlement with University of Maryland Shore Regional Health

The University of Maryland Shore Regional Health will pay $296,870 to settle allegations that it violated the False Claims Act.

whistleblowersblog.org

False claims act mandates 20k per incident on top of treble damages. At this level settlement, he wasn’t there like maybe at most 5 to 10 times over a many year period. Pretty picky, DOJ.

 

[RickyScott]

False claims act mandates 20k per incident on top of treble damages. At this level settlement, he wasn’t there like maybe at most 5 to 10 times over a many year period. Pretty picky, DOJ.

Settlemnt likely reflects almost no chance at winning at trial.

 

[elementaryschooleconomics]

$300,000?

So, like...what Sloan is reimbursed from just 31 Keytruda infusions?

And the whistleblower only got $50k?

Google being the terrifying machine that it is, the whistleblower is gainfully employed in the field and is a current voting member of an AAPM task force subgroup.

I will be making sure to never be in this guy's vicinity...ever? Ever.

 

[TheWallnerus]

$300,000?

So, like...what Sloan is reimbursed from just 31 Keytruda infusions?

And the whistleblower only got $50k?

Google being the terrifying machine that it is, the whistleblower is gainfully employed in the field and is a current voting member of an AAPM task force subgroup.

I will be making sure to never be in this guy's vicinity...ever? Ever.

His attorney got half. He was good to get 25K. And after taxes, 15K. That whistleblower life yo

 

[elementaryschooleconomics]

His attorney got half. He was good to get 25K. And after taxes, 15K. That whistleblower life yo

I guess, giving everyone the benefit of the doubt -

Perhaps there were systemic/cultural issues in this department that couldn't be fixed despite multiple attempts. As we all know, there are innumerable "bad" or "unsafe" things that are not covered by any laws or boards. Maybe calling out this one specific thing was the only way to force change, and the physician/staff knew it was happening and approved of it?

 

[medgator]

His attorney got half. He was good to get 25K. And after taxes, 15K. That whistleblower life yo

Yep... I wouldn't bend over to pick up a nickel or whistleblow for 5 figures

 

[StIGMA]

$300,000?

So, like...what Sloan is reimbursed from just 31 Keytruda infusions?

And the whistleblower only got $50k?

Google being the terrifying machine that it is, the whistleblower is gainfully employed in the field and is a current voting member of an AAPM task force subgroup.

I will be making sure to never be in this guy's vicinity...ever? Ever.

Whistleblower

 

[medgator]

First rad onc qui tam settlement in years and it didn't even reach 7 figures....

New York Presbyterian Hospital Pays Over $800,000 to Settle Claims that Physician Practices Improperly Billed Government Health Care Programs

“The defendants provided substandard care to cancer patients by not properly or timely reviewing medical imaging and then billed taxpayer funded healthcare programs for these shoddy services,” stated United States Attorney Breon Peace. “My Office is committed to holding healthcare providers...

www.justice.gov

 

[seper]

billing for CBCTs that did not have the approval stamp? non-story, agree

 

[Reaganite]

First rad onc qui tam settlement in years and it didn't even reach 7 figures....

New York Presbyterian Hospital Pays Over $800,000 to Settle Claims that Physician Practices Improperly Billed Government Health Care Programs

“The defendants provided substandard care to cancer patients by not properly or timely reviewing medical imaging and then billed taxpayer funded healthcare programs for these shoddy services,” stated United States Attorney Breon Peace. “My Office is committed to holding healthcare providers...

www.justice.gov

Would love to know the story behind this. Looks like a physician filed the qui tam. Was it a locums? Heard a rumor many years ago there were some locums digging into these sorts of things when they covered practices. Certainly not claiming that was the case here, but reminded me of that.

 

[Wildcat321]

Would love to know the story behind this. Looks like a physician filed the qui tam. Was it a locums? Heard a rumor many years ago there were some locums digging into these sorts of things when they covered practices. Certainly not claiming that was the case here, but reminded me of that.

 

[elementaryschooleconomics]

Oh wow, this case takes on a different flavor knowing the Relator.

I had assumed classic disgruntled therapist or admin. I'm vaguely familiar with her, and my impression was that she is committed to patient care, though FULL DISCLAIMER she could have completely fooled me, of course.

But now I'm assuming she saw some pretty shady things and couldn't let it go.

Total speculation, but I bet IGRT was either forgotten to be checked for several days and/or just rubber stamped consistently, and inpatient consults were more an "electronic chart consult" then billed as Level 5.

Again, total speculation on my part. But the case took 6 years to settle. You only endure that if the money is great - and the money was basically nothing here - or you've got an axe to grind. So you're either really petty or guided by some level of virtue. And doctors, especially mid-career or younger, generally don't do whistleblower cases (where their peers will find out) for simple pettiness.

 

[seper]

Columbia is a notoriously tough place to work, even by NYC standards… I’ve interviewed some of their physicists for a job

 

[brushbeamscanning]

Columbia is a notoriously tough place to work, even by NYC standards… I’ve interviewed some of their physicists for a job

I'm sure that's true for Columbia, but probably the same holds true for NYP Methodist.

 

[medgator]

I'm sure that's true for Columbia, but probably the same holds true for NYP Methodist.

Isn't that the malignant residency program that shut down a few years ago (Cornell)?

 

[seper]

yeah 2 RadOnc departments are sharing the hospital system

 

[RickyScott]

yeah 2 RadOnc departments are sharing the hospital system

3 departments. New York Methodist also had/has a residency. Cornell is using this to get around the shut down as Methodist residents were increased and now rotate through Cornell.