Supervision and Fraud?? a few questions...

[Era 142]

So here are my questions...
1) How many people do not have an attending present during the night shifts? Where I am a resident, we do not have an attending in house at night EXCEPT the ED doc, who is usually busy enough that they can not leave the ED. We have no intensivist, IM, surgeon in house, so we are it. There are 2 interns and a PGY-2 or 3, and that is it. Do most places do this, or is our program a unique one?

2) At night when there is a code and we intubate, place lines, and so forth, we also do not have an attending in present. No biggie, we know lines/ACLS very well after internship due to the exposure and quantity that we are exposed to. Our attendings are present BY PHONE. due to this, they bill for our intubations/lines. I feel this is fraud. They were not present for the majority of the procedure and/or code, so they should not be able to bill for this. Am I correct, and what can be done about this? Any help would be greatly appreciated...

---

Members don't see this ad.

 

[sikegeek]

So here are my questions...
1) How many people do not have an attending present during the night shifts? Where I am a resident, we do not have an attending in house at night EXCEPT the ED doc, who is usually busy enough that they can not leave the ED. We have no intensivist, IM, surgeon in house, so we are it. There are 2 interns and a PGY-2 or 3, and that is it. Do most places do this, or is our program a unique one?

2) At night when there is a code and we intubate, place lines, and so forth, we also do not have an attending in present. No biggie, we know lines/ACLS very well after internship due to the exposure and quantity that we are exposed to. Our attendings are present BY PHONE. due to this, they bill for our intubations/lines. I feel this is fraud. They were not present for the majority of the procedure and/or code, so they should not be able to bill for this. Am I correct, and what can be done about this? Any help would be greatly appreciated...

I know at my hospital, certain doctors have to be in-house in order for us to be a "level-one trauma center"-I think a trauma surgeon and an OB. Other than that, residents do eveything else. lines, etc. If you're not a level-one, maybe there doesn't have to be anyone in-house besides ER docs.

I don't think it's fraud. I assume the attending will have legal responsibility, but there is probably some provision in malpractice inurance that covers if a resident messes something up without an attending there at a teaching hospital. Our upper levels have to do so many procedures and get "signed off" on them, so they can be trusted to do them without messing them up.

Look at it like this: I think it's more a privilege than fraud. Somebody has to bill for the procedure. The resident can't do it. The resident needs practice. I don't know who actually gets paid- maybe noone if the pt is indigent. When you are an attending, do you want to sleep in the hospital every 4th night when it is your turn to take call? Esp since the reidents can handle a lot of things and need to have some autonomy to learn how to handle things.

 

[BADMD]

So here are my questions...
1) How many people do not have an attending present during the night shifts? Where I am a resident, we do not have an attending in house at night EXCEPT the ED doc, who is usually busy enough that they can not leave the ED. We have no intensivist, IM, surgeon in house, so we are it. There are 2 interns and a PGY-2 or 3, and that is it. Do most places do this, or is our program a unique one?

2) At night when there is a code and we intubate, place lines, and so forth, we also do not have an attending in present. No biggie, we know lines/ACLS very well after internship due to the exposure and quantity that we are exposed to. Our attendings are present BY PHONE. due to this, they bill for our intubations/lines. I feel this is fraud. They were not present for the majority of the procedure and/or code, so they should not be able to bill for this. Am I correct, and what can be done about this? Any help would be greatly appreciated...

If they are submitting a bill to Medicare/Medicaid for services they were not physically present for, they may be committing fraud. However, there are exceptions, nuances, and larger factors that you may or may not be aware of. For example, if the resident performs the procedure, without direct supervision, the hospital may be able to bill for the hospital portion, without the physician billing for the physician portion.

A second concern is that you guys have no back up. Wow. I consider myself a fair hand with an ET tube, but I've met a few airways I couldn't tube. I also hope, without surgical back up, that you have no chest tube complications.

What can be done? Well, you can let Medicare/Medicaid know. That might create someother issues. You could also ask your department administrator about it.

 

[Pilot Doc]

Lots of interesting questions - lots of confusing answers comingling several issues

1) Malpractice - varies by state and carrier, but there is a long, long history of residents being "supervised" by attendings not physically present - no issue there.

2) Level 1 Trauma Center - generally a certification issue with the American College of Surgeons and possibly your state. No crime/fraud issues here

3) Good Medical Care - Hard to argue that some sort of in house attending coverage wouldn't be better, but again, there is a long history of residents running the ship at night. This is changing somewhat (I think it's illegal in NY state), but I don't think it has yet slipped below standard of care.

4) Billing - in general, billing for a service when you were never physically present is fraud, in some cases criminal. This is an issue ONLY for the attending. As the resident, this is not your issue. You provide medical care, you don't bill for it personally. End of story. There's no reason you have to do anything about it, and I would leave it alone. If you feel compelled to pursue it, however, you should talk to an attorney. There are whistleblower statutes that let you get a cut of the money the government recovers in a fraud investigation.

 

[Smurfette]

At the three hospitals I rotate in as a (surgery) resident,

Hospital #1 (university hospital): no in-house surgery attendings. Guaranteed to have at least a PGY-3 or above surg resident on call....who is quite possibly the most senior person in-house outside the ER. There are ER attending(s) 24-7 (who do not respond to codes on the floors), and possibly an anesthesia attending, OB attending and a medicine attending in-house at any given time...depending on exactly how late/early it is. NEVER outside of the OR or ER in 3 years have I seen an attending participate in a code on 2nd or 3rd shift except for anesthesia, who tubes the patient and then leaves. Never had an attending ask about lines for billing purposes.

Hospital #2 (county hospital): In-house ER attending and trauma attending, both of whom stay in their "areas". One anesthesia attending in-house who doesn't come to codes unless the anes. resident on-call is a CA-1 or pages them for help. Possibly a fellow on call in one of the ICUs, but not to be counted on or expected to respond to anything outside of their immediate ICU realm. Always a medicine senior resident and surgery senior resident in-house. Never seen an attending in a code outside of OR/ER at any time unless attending found the patient and called the code blue. Never heard of attendings billing for lines and stuff...then again, our patients are indigent and usually unable to pay anyway.

Hospital #3 (small private community hospital): one ER attending in-house. guaranteed one medicine pgy-2 or 3 on call, plus 50% chance of surgery pgy-2 or 3 on call versus an intern. No other attendings of any kind in house unless called in for specific emergent reason (i.e. surgery, cath, OB). ER attending does not respond to codes unless in ER. Attendings likely to bill for lines placed/procedures done by their residents.

I don't know how the coding thing works as far as billing for procedures. Frankly, if an attending is on the phone and is asking for lines/procedures to be done, maybe that is legit since they have a presence there (though not a physical one). I know many times for me, we do procedures (chest tubes, lines, etc.) on a crashing/coding/unstable patient and then call the attending once we have time to talk to the attending...in which case I think billing for it is a bit shady, but then again, I don't know the laws involved.

 

[Faebinder]

You are doing a procedure. Someone's a$$ is on the line. Someone gotta bill. I vote the attending being able to bill since the resident can't bill. Should the resident be able to bill? That's a different debate.

As for attending not being present at night, well you gotta fly solo sometime.

 

[3dtp]

You are doing a procedure. Someone's a$$ is on the line. Someone gotta bill. I vote the attending being able to bill since the resident can't bill. Should the resident be able to bill? That's a different debate.

As for attending not being present at night, well you gotta fly solo sometime.

Hospitals are paid for GME by CMS/Medicare. Services provided exclusively by residents are not billable to Medicare/Medicaid. End of story.

The change came about in the late '70s early '80s when hospitals pleaded that the then new DRG billings did not account for training of residents and asked for and received direct and indirect compensation for training residents.

Several universities got into serious fraud trouble with HCFA now CMS for billing for residents procedures without an attending present, including fines of millions. This lead to the addendum phrase to our notes by attendings, "I agree with the history, physical findings and plan of care proposed by the residents." Nay, said HCFA, not good enough. You have to be present to bill for resident's work, not just a retrospective reviewer. So, the new phrase "and was present during the critical portions of the history, physical, evaluation and procedures," was added.

There are certain exceptions in primary care fields after six months, but these are limited. As of now, residents can do anything they are privileged to do on their own. The catch is that hospitals and attendings cannot legally bill for procedures that they are not phyically present and supervising a resident.

Scenario: Chest tap needed. Senior res and intern call attending, who agrees and perform the tap. All is well, and duly noted in the chart. Attending never shows up for the procedure, but later reviews the chart and signs a note. The hospital billers then charge Medicare for the procedure. This is fraud.

Scenario: Chest tap needed. Senior res and intern call the attending who comes to patient room, reviews xray and examines patient. Chest tap is performed by resident and intern while attending, chats with patient. Att signs note and biller bills. This is legal. Attending was there to verify the need (evaluation and management), supervise the procedure. Not Fraud.

So, if the hospital does not bill for procedures done when there is no attending, there is no problem. If they do there is a problem and a direct violation of the False Claims Act of 1869. This law was passed to prevent people from stealing from the government.

 

[Coastie]

Sounds very very very familiar. I agree with your assessment of the situation.

I've known of PA's and ARNP's at some institutions doing lines and LP's, unsupervised, and drop the bill, or even known to have them supervise residents (with bad outcomes, as well).

Interesting.

So here are my questions...
1) How many people do not have an attending present during the night shifts? Where I am a resident, we do not have an attending in house at night EXCEPT the ED doc, who is usually busy enough that they can not leave the ED. We have no intensivist, IM, surgeon in house, so we are it. There are 2 interns and a PGY-2 or 3, and that is it. Do most places do this, or is our program a unique one?

2) At night when there is a code and we intubate, place lines, and so forth, we also do not have an attending in present. No biggie, we know lines/ACLS very well after internship due to the exposure and quantity that we are exposed to. Our attendings are present BY PHONE. due to this, they bill for our intubations/lines. I feel this is fraud. They were not present for the majority of the procedure and/or code, so they should not be able to bill for this. Am I correct, and what can be done about this? Any help would be greatly appreciated...

 

[Faebinder]

Hospitals are paid for GME by CMS/Medicare. Services provided exclusively by residents are not billable to Medicare/Medicaid. End of story.

The change came about in the late '70s early '80s when hospitals pleaded that the then new DRG billings did not account for training of residents and asked for and received direct and indirect compensation for training residents.

Several universities got into serious fraud trouble with HCFA now CMS for billing for residents procedures without an attending present, including fines of millions. This lead to the addendum phrase to our notes by attendings, "I agree with the history, physical findings and plan of care proposed by the residents." Nay, said HCFA, not good enough. You have to be present to bill for resident's work, not just a retrospective reviewer. So, the new phrase "and was present during the critical portions of the history, physical, evaluation and procedures," was added.

There are certain exceptions in primary care fields after six months, but these are limited. As of now, residents can do anything they are privileged to do on their own. The catch is that hospitals and attendings cannot legally bill for procedures that they are not phyically present and supervising a resident.

Scenario: Chest tap needed. Senior res and intern call attending, who agrees and perform the tap. All is well, and duly noted in the chart. Attending never shows up for the procedure, but later reviews the chart and signs a note. The hospital billers then charge Medicare for the procedure. This is fraud.

Scenario: Chest tap needed. Senior res and intern call the attending who comes to patient room, reviews xray and examines patient. Chest tap is performed by resident and intern while attending, chats with patient. Att signs note and biller bills. This is legal. Attending was there to verify the need (evaluation and management), supervise the procedure. Not Fraud.

So, if the hospital does not bill for procedures done when there is no attending, there is no problem. If they do there is a problem and a direct violation of the False Claims Act of 1869. This law was passed to prevent people from stealing from the government.

*cough*... happens... *cough*... so much *choke*...

Mmmm.. On the other hand, have a PA supervise the chief resident to be able to bill? mmm.. That's so much garbage I'm trying to gag and vomit at the same time "Dr. Cox: I'm Ga-vomiting."

 

[Winged Scapula]

*cough*... happens... *cough*... so much *choke*...

Mmmm.. On the other hand, have a PA supervise the chief resident to be able to bill? mmm.. That's so much garbage I'm trying to gag and vomit at the same time "Dr. Cox: I'm Ga-vomiting."

That happened to us on CT Surg. The attendings couldn't bill when we removed or placed a chest tube but could when the PA did. Quickly it was realized and guess what...either the PA did all the tubes or had the residents do them while they "supervised".🙄

 

[f_w]

Whenever I did procedures without 'direct' or 'personal' supervision, my procedure notes had to carry a 'note to biller, no professional charge' right after the procedure header.

Different procedures carry different supervision levels in the medicare universe. Some can be performed under 'general' supervision (no need for attending presence), others require 'direct' supervision (attending in same building) some require 'personal' supervision (attending in procedure room).

The hospital is able to bill for the technical component of a procedure, regardless of who performs it (in the case of DRGs it actually doesn't matter whether the hospital 'bills' for it or not, it is already included in the DRG). Hospitals are restricted from billing the professional charge if the work is done by a resident without attending supervision.

 

[docB]

For all those who are shocked at this unending rat's nest of rules, policies and procedures I say "Welcome to the most over regulated industry on Earth." I would also like to point out that while there is some agreement on what you can do and what you can't do most of it is based on case precedent which means someone had to get thrown under the truck for the rule to get made. The government is notoriously reluctant to define what the rules are because they know you'll meet the minimums and no more. They are much happier when everyone is kept guessing.

 

[elwademd]

So here are my questions...
1) How many people do not have an attending present during the night shifts? Where I am a resident, we do not have an attending in house at night EXCEPT the ED doc, who is usually busy enough that they can not leave the ED. We have no intensivist, IM, surgeon in house, so we are it. There are 2 interns and a PGY-2 or 3, and that is it. Do most places do this, or is our program a unique one?

your program is not unique in that regard.

2) At night when there is a code and we intubate, place lines, and so forth, we also do not have an attending in present. No biggie, we know lines/ACLS very well after internship due to the exposure and quantity that we are exposed to. Our attendings are present BY PHONE. due to this, they bill for our intubations/lines. I feel this is fraud. They were not present for the majority of the procedure and/or code, so they should not be able to bill for this. Am I correct, and what can be done about this? Any help would be greatly appreciated...

unless you see the billing sheets that are actually turned in to the proper departments... and see the results of those billing sheets (whether procedures/servives billed are actually paid out)... then in some ways, one could say that you actually don't know whether fraud is being committed or not. it seems that, at this point, you feel that fraud might be committed.

an easy starter would be to ask the attendings themselves their opinion on the subject.

Hospitals are paid for GME by CMS/Medicare. Services provided exclusively by residents are not billable to Medicare/Medicaid. End of story.

The change came about in the late '70s early '80s when hospitals pleaded that the then new DRG billings did not account for training of residents and asked for and received direct and indirect compensation for training residents.

Several universities got into serious fraud trouble with HCFA now CMS for billing for residents procedures without an attending present, including fines of millions. This lead to the addendum phrase to our notes by attendings, "I agree with the history, physical findings and plan of care proposed by the residents." Nay, said HCFA, not good enough. You have to be present to bill for resident's work, not just a retrospective reviewer. So, the new phrase "and was present during the critical portions of the history, physical, evaluation and procedures," was added.

There are certain exceptions in primary care fields after six months, but these are limited. As of now, residents can do anything they are privileged to do on their own. The catch is that hospitals and attendings cannot legally bill for procedures that they are not phyically present and supervising a resident.

Scenario: Chest tap needed. Senior res and intern call attending, who agrees and perform the tap. All is well, and duly noted in the chart. Attending never shows up for the procedure, but later reviews the chart and signs a note. The hospital billers then charge Medicare for the procedure. This is fraud.

Scenario: Chest tap needed. Senior res and intern call the attending who comes to patient room, reviews xray and examines patient. Chest tap is performed by resident and intern while attending, chats with patient. Att signs note and biller bills. This is legal. Attending was there to verify the need (evaluation and management), supervise the procedure. Not Fraud.

So, if the hospital does not bill for procedures done when there is no attending, there is no problem. If they do there is a problem and a direct violation of the False Claims Act of 1869. This law was passed to prevent people from stealing from the government.

you bring up some points that seem to make it more likely to just admit patients to medicine/hospitalist service for the hospitalization... and then consult surgeons for procedures... admissions are not services, as well as consults... the procedures themselves are, but if the patient has been admitted, and there has been a consult to which the procedure is tied... then the service was not exclusively provided by the residents.

in any event, there is also a difference between the charges that the hospital would like to recoup, and those which the physician would like to have reimbursed.

in your scenario, the "chest tap" may not be reimbursed... which affects the hospital very little (cost of the materials/supplies involved), but the hospital still gets paid for the hospitalization... its the physician(s) who may end up suffering as a result of not getting paid for the procedure... but then again, if the attending wasn't there, then i suppose it's no sweat of his/her back!

 

[Faebinder]

Well as stated above.. medicare is supposedly paying direct medical education compensation to the institution and the institution is after all paying the hospital and the attending.

That is taken for granted of course. Note in case of a PA doing a procedure, GME never paid for him to begin with, so he should be able to bill.

 

[Dr. V]

This is why the private attendings want you to dictate a very good, thourough consult when you place a line/chest tube.

They can legally bill for the consult, but can't bill for the line if they weren't there (who knows if lines are one of those exceptions or not, just using it as an example).

They CAN however be paid for the consult, and if you dictate a very good, complete H&P type consult for them they will apprecite it.

 

[f_w]

Well as stated above.. medicare is supposedly paying direct medical education compensation to the institution and the institution is after all paying the hospital and the attending.

Outside of city, VA and charity hospitals, it is extremely rare that a hospital pays the attending salary.
In most university settings, there is a faculty practice plan which is essentially a large multispecialty practice. They bill the professional fees for the attendings work.

The hospital is precluded from billing for residents professional work as they already received 100k+ DME and IME payments from CMS to cover those services. Residents are indirect employees of the federal goverment, your hospital just serves as a conduit so the feds don't have to deal with the administrative work.

 

[f_w]

Another funny tidbit. If you admit someone, and then you do a 'procedure' such as a thoracentesis, some insurance plans see that as evidence that you admitted the patient for that procedure (and proceed to cancel out the charge for your initial H+P as well as the next couple of days of in-hospital services as those are bundled into the $15 you got for the thora). As a result, PCPs or hospitalist services often try to consult someone else (surgery or IR) to perform those procedures.

 

[Faebinder]

Another funny tidbit. If you admit someone, and then you do a 'procedure' such as a thoracentesis, some insurance plans see that as evidence that you admitted the patient for that procedure (and proceed to cancel out the charge for your initial H+P as well as the next couple of days of in-hospital services as those are bundled into the $15 you got for the thora). As a result, PCPs or hospitalist services often try to consult someone else (surgery or IR) to perform those procedures.

😡😡😡 That's why i think we should just out right not accept insurance to pay for doctor fees. There should only be insurance for hospital fees. But to do that you'd have to convince everyone that they should start prefering patients who pay privately their doctor fees over those who let insurance handle it... but then you'll face those who feel doctor's health services are a right, not a privilage. When I say prefering, I mean something like cherry picking whom you operate on first or take-care/accept-as-a-patient of first in none emergent cases.

The only problem is that medicare puts a few sentences in its contract about not allowing cherry picking. Gosh, held by the balls eh?

 

[f_w]

n(posts)>10 --> Q (faeb) goes against 1

n(posts) is the number of posts in a thread.

Q(faeb) is the likelihood of Faebinder weaving his libertarian anti-goverment rant into the discussion, relevant or not.

 

[Faebinder]

n(posts)>10 --> Q (faeb) goes against 1

n(posts) is the number of posts in a thread.

Q(faeb) is the likelihood of Faebinder weaving his libertarian anti-goverment rant into the discussion, relevant or not.

Alright, alright I'll give. I need a break from this crazy article work i'm doing anyway. 😎

 

[3dtp]

This is why the private attendings want you to dictate a very good, thourough consult when you place a line/chest tube.

They can legally bill for the consult, but can't bill for the line if they weren't there (who knows if lines are one of those exceptions or not, just using it as an example).

They CAN however be paid for the consult, and if you dictate a very good, complete H&P type consult for them they will apprecite it.

They can only bill for the consult, if and only if , they, themselves do the consult. Your note may make it easier for them to obtain the needed elements of the consult to bill at a higher E&M code, but unless they write their own note, essentially repeating the key elements of the consult, they may not bill for it or can only bill at a lower E&M code (Limited or Focused v. Extended) in proportion to what they actually did.

If they don't see the patient, they cannot bill for it. This only applies to Medicare as far as I know. I do not know how it applies to non Medicare/Medicaid patients as that is a function of insurance contracts.

This is why the attendings must be available for the consult and must physically see the patient. The resident doesn't have to be there when they do, but they must see and examine the patient to be paid.

Concerning F_w's comment on the practice of having medicine admit all patients, then consult surgery/cardiology/gi/gu/you pick two, and ewald's comments as well, this is precisely what suburban, well healed hospitals do to maximize revenue streams. Medicine admits everyone, including those known to be headed for surgery, for "pre-op work up and medical clearance." Then surgery is consulted for the underlying conditions requiring surgery.

If surgery admits a patient, then medicine is consulted to pre-op the patient. These are the same accounting folks who brought you the $40 ASA and the $200 hammer that NASA uses.

And as docB says, the games go on.

Pete Seeger, an old folk singer wrote a song a long time ago, it begins with

I sold a hammer to the Pentagon and I'm a millionaire.
You can sell a nail to the Pentagon and you can be a millionaire too.

The last of the many verses is

I sold a toilet seat to the Navy and I'm a millionaire.
You know what you can sell to the Navy and you can be a millionaire too.

Hospitals hire very expensive Harvard MBAs to figure out how to do this and those that do it well have marble entrances. Those who don't are county hospitals.

 

[TeleoDeum]

One other variation on this theme... If I run a code as a fellow, perform an intubation, possible lines, tubes, etc..., the patient is likely moved to the PICU. If the attending was not present for the code, then they cannot bill for the code services, but they CAN bill for the PICU admission and services, which are at a much higher payout. This ICU daily billing includes individual procedures in the unit (ie intubation, lines, etc...) as these things are "bundled" into the admission charges. So even if the attending was not specifically present while they were done, they still get paid.

 

[Dr. V]

They can only bill for the consult, if and only if , they, themselves do the consult. Your note may make it easier for them to obtain the needed elements of the consult to bill at a higher E&M code, but unless they write their own note, essentially repeating the key elements of the consult, they may not bill for it or can only bill at a lower E&M code (Limited or Focused v. Extended) in proportion to what they actually did.

I could be wrong but I am pretty sure all they need to do to get paid for the consult is sign my note complete with that little phrase "seen and chart reviewed, yada yada". It's about 3 lines that medicare requires and that's pretty much it and all they have to do is sign the dictation. There is no requirement for them to come in at 3am and see the consult when I do it, just that they sign my note the next day while rounding and physically see the patient so it really does make it convienent for them. (As it should because they are taking time out of their day to teach us and there is no doubt a surgical attending can get more done quicker without a resident in the way, we take more time to do the case than they would).

 

[MacGyver]

That happened to us on CT Surg. The attendings couldn't bill when we removed or placed a chest tube but could when the PA did. Quickly it was realized and guess what...either the PA did all the tubes or had the residents do them while they "supervised".🙄

For the love of god please give us the name of this program. I sure as hell wont be applying there and if everybody else knew what was going on, they'd have to settle for FMGs and destroy the rep of their program.

I'd also like to shoot off some nasty emails to the program directors/administrators to remind them that they are total sellouts and should work in a private practice group thats not affiliated with a university medical center if they want to screw the residents over with piss poor training.

 

[Winged Scapula]

For the love of god please give us the name of this program. I sure as hell wont be applying there and if everybody else knew what was going on, they'd have to settle for FMGs and destroy the rep of their program.

Its no secret where I did my residency.

I'd also like to shoot off some nasty emails to the program directors/administrators to remind them that they are total sellouts and should work in a private practice group thats not affiliated with a university medical center if they want to screw the residents over with piss poor training.

You wouldn't be the first...its one reason they pulled the 3rd years off CT Surgery.

 

[Misterioso]

Hey, don't rock the boat. When you're an attending you can be phoning in your procedures to some fresh-off-the-boat FMG resident while you're comfortably in bed at your mansion with the two escorts you rented for the night.

 

[3dtp]

I could be wrong but I am pretty sure all they need to do to get paid for the consult is sign my note complete with that little phrase "seen and chart reviewed, yada yada". It's about 3 lines that medicare requires and that's pretty much it and all they have to do is sign the dictation. There is no requirement for them to come in at 3am and see the consult when I do it, just that they sign my note the next day while rounding and physically see the patient so it really does make it convienent for them. (As it should because they are taking time out of their day to teach us and there is no doubt a surgical attending can get more done quicker without a resident in the way, we take more time to do the case than they would).

I beg to differ. You cannot, legally, do this.

This has been the case since 1996, at least. I cite the HCFA (forerunner of CMS) Regulation entitled Teaching Physician Presence Rules (45 CFR 4172(a)). This regulation states, as far as documentation is concerned, "the medical records must document that the teaching physician was present at the time the service was furnished. The presence of the teaching physician during procedures may be demonstrated by the notes in the medical records made by a physician, resident, or nurse, though a mere countersignature or boiler-plate link to a resident or nurse's note is now expressly deemed insufficient for these purposes. Physical presence is defined as being located in the same room (or partitioned/ curtained/subdivided area) as the patient and providing a face-to-face service." [Highlights mine.]

These rules are still very much in operation today and require two elements to bill: you have to be present and you have to have documented that presence personally in the medical record or it is indeed fraud, at least according to the government and the goverment makes the rules.

Concerning admission H&Ps and other E&M billings under Medicare B, since 1995, the attending himself must document what he did, personally. He cannot rely on a resident's note for this purpose. He can countersign and agree with it, but to be paid, he must write his own note documenting his personal H&P, findings and plan, or the E&M cannot be billed. This is why there are rounds, so the attending can discuss the case, and the plan, but also to financially be able to say that the attending has seen the patient, evaluated the patient, and developed a management plan that the residents can implement.

Since 1995, the attending, not the resident, must clearly indicate in the patient record, the patients history, family medical history, systems reviews, physical exam, the health issues discussed with the patient, complexity of the medical decision making and the next steps in the care. Then and only then can an attending bill Medicare Part B, without the risk of fraudulent billing.

Most attendings regarded these regulations at the time they were published as a collossal pain and negated a good deal of the reasons they had residents.

But HCFA/CMS took the other perspective: residents were licensed in many states, they took direct care of the patients and if they were providing services, the government had already paid for those services as part of the prospective payment system worked out with hospitals who swore a decade earlier that residents were trainees who cost them money and didn't contribute appreciable to the patient care, and that only the attendings did. In the '80s the hospitals got their way, got medicare funding for residencies, but then got caught double dipping and this was the government's response.

You are correct, the attending does not have to appear at 3AM for the consult/admission, but if they/hospital bill for it, they'd better be there at some point, soon, and they'd better have written their own note.

None of this is particularly relevent to the educational goals, except that it encouraged close coordination between resident and attendings. It is about CMS's concern that it is not paying twice (DMEA/IMEA and Medicare Part B) for the same service rendered.

And...just around the corner...single payer/socialized indenturement?

 

[f_w]

You are correct, the attending does not have to appear at 3AM for the consult/admission, but if they/hospital bill for it, they'd better be there at some point, soon, and they'd better have written their own note.

What seems to happen often in these situation is that the attending reads the residents note, walks into the patients room in the morning, briefly reviews some of the pertinent points, lays his hands and then verbatim re-dictates the residents note. (technically, that attending should only bill for the level 2 consult services he personally provided, in reality they will bill the level 4 service they can document based on the residents leg work).