Monday, December 22, 2008

Calling All Lawyers

I wonder if Dev and Co. might help me here. Here's a good law school hypothetical. Let's imagine, in a world gone mad, that hospitals were run by clipboard-carriers and that said folk worked for corporation Z. Let's say corporation Z saw the ER hemorrhaging money and put the word out that in order for dumb old Dr. B down in the ER to continue to have his job that he had to call a consultant on a certain percentage of the patients he saw in said ER. 

In doing this the admission rates of the hospital would climb (specialists consulted after 10pm are likely to just say, "admit them and I'll see them in the morning), their ER waits would go up, their 'left without being seens (LWOBS)' would increase, their satisfaction scores would plummet (but these are easily doctored), but their bottom line would be nice because of the following:

A. Lot's of folks admitted who would not otherwise be admitted and the money flows. 
B. Lot's of specialty consultation fees and procedure fees.
C. Lot's of patients leaving 'against medical advice' from the ER, allowing more aggressive collections directly from the patient as insurance providers will often not cover ER visits which end with the patient leaving "AMA". 
D. Lot's of 'self pay' patients who are not truly ill are triaged to eternity and are never seen as they simply leave after an 8 hour wait (see LWOBS above).  
E. Lot's of leverage with the ER docs who fear for their jobs if their numbers aren't right... Lot's less lip from 'em.
F. EMTALA is skirted, which is, to me, quite a beautiful thing in that it demonstrates the FACT that unfunded mandates will always be skirted, and, in this process, billions of dollars and millions of trees are wasted. 

What say you, you of the august profession of OWH Jr.? It is my belief that this is happening in many hospitals nationwide and I have proof. All I ask is that I get a measly 2% of the award in the qui tam action or whatever the hell you think would work. 


  1. Are you asking if there is a crime? Potentially fraud if there is intentional billing of procedures not performed, otherwise I dont really see anything but I am just a teeny tiny law student.

  2. Believe it! EDs are now being used to suck in more revenue for floundering hospitals. Why plus-up your up-stairs capacity to keep the ED empty when you can stuff it to the gills with admitted patients (and you have "extra" nurses for "free") and chase off the non-payors or those patients who eat up nursing time but have the gall to not require medications or other billable nursing or hospital actions.

    Who loses? The patients and ED docs who see their revenues go down and their risk go up.


  3. We'll see what the lawyers say, but in my humble opinion, if - as you say - Corporation Z is doing this, it has already carefully checked the legality of its actions before it embarked on such a journey...

  4. a few clarifications. no doubt the company of lawyers has been consulted and i would be surprised if any of this were committed to writing, rather, it is 'suggested' or 'optimal' and ties in directly with the EMR issue, as these edicts are generated by garbage data spat out of an EMR.

    for example, an EMR may 'flag' a chart if, say, an 80 year old woman with abdominal pain was discharged from the ER without a CT scan. the ER doctor is then asked to explain why he disagreed with the computer and asked to explain why a surgeon was not consulted. GIGO in life and death is so silly it is banal.

    but the issue here is fraud perpetrated on the government, for many of these patients are medicare/medicaid, and per the board certified ER doc's unfettered judgement they are well enough to go home.

    now we have all sorts of behind the scenes pressure, perhaps approaching a form of extortion, for ERs are staffed with contracted physicians, and ER groups are easily and quickly replaced, and why not order that CT scan, and why not consult that surgeon if the company Z president wants better numbers.

    this is where i am absolutely ashamed of my colleagues for not going straight to the local TV station or newspaper or at least telling the computer driven corporate idiots to either come in and see the patients themselves or fuck the hell off. ashamed. hawkeye, where are you? trapper? all retired?

  5. an emr can "flag" a chart? how does this work?

  6. The hospital would be perpetuating a fraud if they are charging the govt for procedures not performed. The feds would be hard pressed to prosecute for fraud otherwise, not to mention the resources involved in prosecuting. There needs to be intent to defraud for a crime and I would seriously doubt charges would come.

    Exposure to the media as you know would either force the Hospital to cease the practice or just push them to make it more complicated to continue.

  7. this is where i am absolutely ashamed of my colleagues for not going straight to the local TV station or newspaper or at least telling the computer driven corporate idiots to either come in and see the patients themselves or fuck the hell off.

    Quite right. Someone oughta write a book about it.

  8. The proof of intent is the problem--it's always the problem. Proof that it is happening wouldn't be enough. Reminds me of my first divorce.
    And 911--forget the qui tam action and go play mini golf with the kids while they're still young. The case would consume years of your life and a billion dollars, and your kids would be full-grown therapy patients/high school dropouts by the time appeals were exhausted. And your wife would realize that this single parenting thing is a snap...


    sorry, still gonna yell and scream about it if only to tell patients to beware and to put their ears to the ground and listen to find out where the nearest well run hospital is located. if the mailman says the local hospital is terrible, he's probably right.

  10. 911,

    In all seriousness, start your own group, I can tell you that there are a few groups that do great that were founded and run by real "in the trenches" ED Docs.

    One in particular works a half-schedule in addition to owning/running a group.

  11. When NASA was run by scientists, we went to the moon. Now that it is run by lawyers, politicians and bureaucrats, we can occasionally land on Mars between crayzee astronauts in diapers, shuttles blowing up and lost Mars mission landers. I like to call it AlGoreification... the process of an unqualified despot religiously dictating policy to the masses.

    Now that hospitals are becoming AlGoreified, is it any wonder that we see stuff like this?

    So, let's up the ante. Suppose said hospital Z sent an email out to the ER Docs that the percentage of Medicare admits for condition X is 20% and you are only admitting 10%, so let's improve the admission rate. Does this show intent to defraud medicare?

  12. 911: Well, it's not the White Hats that suffer as much as their families. I was married to a civil rights attn. crusader, and I was not the first nor last Mrs. W.H. At least it was an easy divorce, as he was too busy saving the world to pay much attention. This was actually my only divorce.
    And he's not a happy man, but he never has been. Hate to see you go that route.

  13. I suppose there could be a civil action on the part of the feds to recover and penalize the hospital, but again, an expensive effort with a low likelihood of return. It just isnt worth it.

  14. don't worry dev. i'm not a crusader but i am a fighter. simply hoping that the word gets out that many hospitals are making up for the lost revenue of EMTALA by dirty dealings and dishonesty. if there ARE any crusaders out there then i'll be happy to follow behind as i continue to work. Merry Christmas everyone, you know, Christ's birthday etc...

    what you are describing is, i believe, a 'qui tam' action and no doubt you are right. however, the government has thousands of lawsuits out their against individial physicians for fraud and i don't know why they wouldn't be interested in the truly deep pocket. my suspicion is that it would make them look silly because this is all the result of their bungling in the first place.

  15. igloodoc,
    are you ER? are you in alaska? always enjoy your comments, algore is in the result of the 'peter principle' and it seems that's what most folks are comfortable with.

  16. merry christmas to all you cantankerous docs...keep it real and honest for ya

  17. wtf does "gigo" mean!@&^%


  18. Dear Oldfart,
    I see that knock on your Mellon has not made you smarter or more deft with prose...

    GIGO= garbage in, garbage out