Wednesday, October 10, 2012

Is It Fraud to Ask Questions?

     The Diane Rehm show on September 25th hosted physicians and other experts who discussed billing fraud in the medical profession, especially now that electronic records make it easier to cheat, they say.
     One speaker, Mr. Fred Schulte, reported that medical billings have increased since the use of electronic records.  He said doctors are prompted to upcode visits, charging insurance companies more, because it's easy to cut and paste documentation with e-records to support higher charges.
     In the question-and-answer period there was a caller named Michelle, who claimed that she had gone to the doctor for a simple problem, but her insurance company was billed for much more.  She considered it an example of fraud, that her doctor had asked questions that were outside the purview of her visit, unrelated to the simple problem.  She got on-line to "research this issue," and saw that other people were having the same experience, and were angry about it.  "Doctors can boost their billing by asking a few more questions about general health in order to justify a higher billing code...that's unethical, at best, and fraud in my mind," she declared.
     I was surprised that none of the guests on the show took the doctor's point of view--no one contextualized her complaint.  Instead, two of the guests (one was a doctor) apologized to Michelle that "such a thing could happen."
     I am guilty, I admit, of "asking questions."  The truth is, I often ask so many questions that office visits with my patients get upcoded to reflect the additional work this requires, and a lot of new problems are added to the patient's medical record.  I try to document it all, but in reality the Pandora's Box that gets opened, when you start asking patients questions, is impossible to record in a linear fashion on a busy day in a regular doctor's office.
     I have been under the impression that this is the right way to practice medicine.  I was trained to ask questions, to ferret out the hidden agenda of the patient, and to find out what even the patient would rather not know--but will be angry if I, the doctor, don't discover.
     The biggest cause of lawsuits against family doctors is "failure to find cancer."  Failure to identify other serious, underlying health problems is another charge against doctors.  But we can't "find" these health problems without searching around in the dark corridors of the patient's symptoms and psyche, like detectives with flashlights.  It takes time, and it takes questions.
     Are doctors like me supposed to leave the Pandora's Box of hidden problems alone?  Isn't that why some of us miss serious pathology, and why patients suffer worse problems later on, and why we get sued?
     Are we supposed to wait for Pandora's Box to explode, in order to justify looking at its contents?  That's what insurance companies and people like Michelle are implying.  It's even what some of my patients mean when they say, "I don't want a colonoscopy--if it ain't broke, don't fix it."  Is that good medicine?  Everyone seems to want it both ways.  We doctors aren't allowed to miss anything serious, but neither are we supposed to use the time and tests required to find--or prevent--serious problems.  It's a schizoid message.
     If I look around my pantry and see a few canned goods with bulging tops, indicating that the products are old and full of unwholesome gases, what should I do?  Remove them, replace them, and prevent a big mess?  Or wait until they explode?--at which point the extra time required to clean up the mess, including scrubbing down the entire bespattered pantry, will be considered reasonable to the parties who pay for clean-up--the Michelles and their short-sighted insurance carriers, who don't want us to go looking for bulging cans and other telltale signs of imminent disaster, but will pay ten times as much when a disaster occurs.
     It's like paying for damages in a house fire, but not for the lightning rod that would prevent the fire.
     Patients are, very often, like that pantry--there are disasters waiting to happen.  If I might be able to use my experience, training and special insight to identify a problem early, I'll do it.  The questions I ask are not attempts to cheat or "upcode," and are not evidence of fraud.  Instead, they are proof that I am committed to my patients and will go the extra mile to do the right thing for them.  Some patients reject my recommendations--either they are practicing a false economy, or they really don't want to know what problems might be lurking.  But most patients are grateful that I am so thorough.  Unfortunately--for Medicare and other insurance companies--those questions and medical recommendations cost more money up front.
     If Michelle, age 53, presented to my office with a cold--coughing, phlegm, sore throat--and told me  "all she wanted" was an antibiotic--I could write a prescription and get out of the exam room in record time.  I'd bill a minimal-complexity visit, and move on to my next patient.  In fact, this seems to have become the standard of care--because physicians are afraid of all the Michelles and their livid insurance carriers, who accuse doctors like me of fraud for prolonging the visit with age-appropriate "questions."  Hence the popularity of "Urgent Care Centers."
      Michelle, don't come to my office, because I'm going to ask you a few things that have nothing to do with your cold.  I'm not asking them to make money.  My questions will be aimed at finding out what you're not telling me, and preventing future health problems.  If this is a waste of time and money, someone needs to tell me to stop.
     Here are some of the questions I might ask:

          Do you smoke?  Are you thinking of quitting?
          When was your last mammogram?
          Have you had a colonoscopy?
          How's your vision and hearing?
          Do you drink much alcohol?
          Do you exercise?
          How are your home life and your relationships?
          Are you sleeping well?
          Do you still have periods?
          Have you ever had an abnormal Pap?
          Do you have pain anywhere?
          Are you safe?  Does anyone hit you, or put you down?
          Do you wear a seatbelt?
          Do you use a cell phone in the car?
          Have you had a flu shot, or pertussis vaccination?
          Does anyone in your family have heart disease or cancer?
          Do you worry about your health?
          Are you depressed or nervous?
          Are you exposed to any health risks at work?
          Do you have asthma?  
          Do you have chest pain or trouble breathing?
          Is there anything else you want to tell me?

     If Michelle is right to be angry about these "extra questions that justify a higher billing code," I'm guilty.  If the other talk-show hosts think doctors like me are out to make extra money by taking care of the whole person, my brand of medicine is obsolete.  I need to be apprehended.  The government is right to have me under investigation, and to take all my past earnings, and to shut me down.
     We all need to ask an important question, as we revise our country's healthcare system:  What do we really want from our doctors?  Do we want to tell them exactly what to do?  Do we want to restrict their range of practice to that of a computer algorithm?   Do we prize their special skills, including humanism, for which there is no price?  Do we want volume, or do we want value?


  1. There is quite a gap between treating presenting condition/complaint and inviting a patient to gorge themselves on an all-you-can-eat treatment buffet. I'm not sure what that answer is.

  2. Personally I thinks it a shame that physicians are not allowed to perform testing in their office to prevent future health care problems. Why should a patient develop cancer if it can be avoided by medical screening by physicians before it's too late for the patient. I assure you testing to prevent medical conditions before they arrive is a hell of alot cheaper to wait until the patient has the medical conditions that could have been avoided. Unfortunately, our Government doesn't see it that way and ends up costing the country a huge deficit in the healthcare industry.

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