Resident supervision laws

[Sheerstress]

Can anyone tell me exactly what does the law require as far as resident supervision?

Under strict letter of law, under what circumstances is an attending physician required to be physically present when a resident is working up or doing a procedure on a patient?

Or when, as in virtually any residency program in the country, can a phone call suffice? When does one cross the line from consultation to healthcare fraud?

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[edfig99]

A lot of definitions depend on two things 1. local laws, and 2. Medicare guidelines, since usually commercial insurers follow what medicare does.

Generally, residents have a certain "delineation of privileges" as do attending staff. This list shows what you can/can't do and what type of supervision is needed.

According to the Medicare website (www.cms.gov), at least for diagnostic tests (and it's probably not different for most things)

The Centers for Medicare & Medicaid Services (CMS) defines three levels of physician supervision for the provision of diagnostic tests:
?general? means the procedure is furnished under the physician?s overall direction and control, but the physician?s presence is not required during the performance of the procedure;
?direct? means that in the office setting the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure; and
?personal? means a physician must be in attendance in the room during the performance of the procedure.


These levels of supervision are defined in the regulations at 42 CFR 410.32(b) and are also discussed in section 2070 of the Medicare Carriers Manual. This manual can be accessed via our website at: http://www.hcfa.gov/pubforms/14_car/3b2051.htm#_1_4.

For the purposes of ?direct supervision,? we state the physician must be present in the ?office suite? and ?immediately available? to furnish assistance and direction throughout the performance of the procedure. This does not mean that the physician must be present in the room when the procedure is performed. We believe that use of these terms establishes reasonable parameters while allowing some flexibility to recognize that there are variations unique to individual practices.

i know at my program for example, i can draw bloods and put in an IV under "general supervision" but I couldn't throw in a subclavian line unless I had direct supervision, or do a colposcopy unless it was under personal supervision...all these were delineated for me.

hth

 

[Winged Scapula]

Despite the regulations, it also depends on the hospital and the level of the resident.

For example, I can place central lines, float Swans, place chest tubes, I & D abscesses (at the bedside), debride ulcers, suture lacs, replace gastrostomy tubes, etc. and generally finish cases (ie, close) without an attending in the room.

However, at my level, I cannot start (ie, cut; I can prep and drape, give local anesth) a case without the attending - but my BF, who is a Chief resident (at another hospital) has junior attending priviledges so he is allowed to start and finish cases without an attending - as long as one is immediately available. I have not seen this to be the case at my home program, though...maybe program and attending dependent (as well as resident dependent).

 

[docB]

I was once told that there are very few laws about resident supervision and that individual hospital policies are the main regulatory force on this. There are lots of very specific and enforcable laws concerning who can bill for what a resident does and what level of supervision is required for what level of billing.

 

[edinOH]

When you consider that once you pass step 3 and get your state medical license you are essentially licensed to practice medicine, the question becomes even more complex. Where is the line drawn between resident and independant physician legally?

 

[edfig99]

Originally posted by edinOH
When you consider that once you pass step 3 and get your state medical license you are essentially licensed to practice medicine, the question becomes even more complex. Where is the line drawn between resident and independant physician legally?

the line is pretty clear 🙂 if you are a licensed resident you are still in a training program and so you are not viewed as an independent physician. Your malpractice insurance only covers activities you perform within the scope of your residency. If you try to act as an independent physician, you are essentially working without insurance and that's risky.

Also, being licensed alone is not sufficient for most insurance companies, including medicaid and medicare. They require you to have completed a residency, and show proof. Licensed physicians that are working independently without completing residency (GPs) essentially work on a fee for service model.

 

[Adawaal]

This is an interesting thread. Many hospitals (and even training programs within hospitals) have their own guidelines. Some RRCs may as well. Let's keep in mind, however, that these CMMS (formerly HCFA.... here cited as Medicare) rules refer to physician involvement for the purpose of BILLING ONLY. Anyone can float that Swan, but whether or not it's reimbursable would be the question.

 

[docB]

Originally posted by edfig99
the line is pretty clear 🙂 if you are a licensed resident you are still in a training program and so you are not viewed as an independent physician. Your malpractice insurance only covers activities you perform within the scope of your residency. If you try to act as an independent physician, you are essentially working without insurance and that's risky.

Also, being licensed alone is not sufficient for most insurance companies, including medicaid and medicare. They require you to have completed a residency, and show proof. Licensed physicians that are working independently without completing residency (GPs) essentially work on a fee for service model.

I'd say that this is not generally true. In CA you can be licensed after 1 year of post grad training. As a licensed doc you can moonlight and bill as an attending. If I couldn't have billed medicare, medical and the ins companies I wouldn't have made much money moonlighting.
Now, if all you have is a training license like they give you in some states then you would have trouble billing on your own.

 

[Sheerstress]

Thanks for all the responses. It does seem to be a complex issue.

At the institution where I did some of my training, certain house staff, orthopedics residents in particular, would always see patients for who other services had requested ortho consults from the orthopedic attendings. The residents, like in so many other programs, would see the patient, report back to the attending, and the attending would bill for the consult.

Staff often remarked that they were committing healthcare fraud, although they were saving the attendings a lot of trouble by not having to come into the hospital. I have always wondered exactly what the law said about this.

Regarding licensure, I believe that in MOST states, one can get a full license after only one year of postgraduate training. Whether you can get a job anywhere with that amount of training is another matter, since board certification is required to work at virtually every major heathcare provider in the US.

 

[Winged Scapula]

Originally posted by Sheerstress
Thanks for all the responses. It does seem to be a complex issue.

At the institution where I did some of my training, certain house staff, orthopedics residents in particular, would always see patients for who other services had requested ortho consults from the orthopedic attendings. The residents, like in so many other programs, would see the patient, report back to the attending, and the attending would bill for the consult.

Staff often remarked that they were committing healthcare fraud, although they were saving the attendings a lot of trouble by not having to come into the hospital. I have always wondered exactly what the law said about this.

Unfortunately, if the attendings are billing for the consult/procedure without having seen the patient, it IS healthcare fraud - it doesn't matter whether or not the resident is licensed if the consult is for the attending and/or his surgical group.

 

[Sheerstress]

Unfortunately, if the attendings are billing for the consult/procedure without having seen the patient, it IS healthcare fraud

This is getting a little technical, but if a resident sees a patient as in the above example, who SHOULD do the billing? Or shouldn't the situation happen in the first place?

 

[Winged Scapula]

Originally posted by Sheerstress
This is getting a little technical, but if a resident sees a patient as in the above example, who SHOULD do the billing? Or shouldn't the situation happen in the first place?

Residents are not involved in billing and its vagaries. If I see a consult that is never seen by an attending )ie, because maybe it is an inappropriate consult) or do a procedure without an attending present, the attending does not submit a billing slip for his office staff to process.

Attendings may choose to bill if they wish, or they may find ways around it - ie, I know on one service I worked they had the PA do some procedures because they could bill for it (ie, removing chest tubes) when they could not if the resident did it. The situation does occur but as I stated above, billing without having seen the patient is fraud, as they are not allowed to bill for resident work.

 

[docB]

One of the weird situations that arises with this stuff is that when consulting residents come to the ER and do a procedure the ER attending is often the one who can legally bill for it. The rules are pretty clear that it's the attending in attendance who should get to bill.