First let me say that MOST doctors do not perpetrate ANY scams (as I am sure this post will generate some outrage), however, there are individuals out there who do whatever they can to either stretch the bounds of legality (and ethics) to get some extra cash out of a situation (or to avoid work but still get paid). This is also sometimes done to the patient’s benefit as well (although at the expense of the insurance company - but no one seems to shed a tear for them understandably). Some docs even break the law - however they usually get caught eventually and we read about them in the news.
Here are some examples that I have either directly witnessed or heard about happening.
1. Using “creative” timing of one’s notes (progress notes for admitted patients) - this is much harder to do with electronic charting but very easy with paper. The doc comes into the hospital on day 2 (having not seen the patient on day 1 for whatever reason) and writes TWO notes - one dated day 1, the next dated day 2. He or she surreptitiously slips the day 1 note into the chart amongst the papers from that day. Thus he is paid for two days and not one. This works very well for demented patients who have no idea what is going on - but then again - most patients would never say “hey, my doc did not see me on Tuesday but I see he billed for doing so!” This is totally illegal.
2. Like above but even more “creative” (and not as overtly illegal) - The doc comes in to see a patient (I witnessed this many times with one doc in particular in the CCU) at about 11pm. He or she writes a note after examining the patient. Then he/she waits around until 12:15am , and checks a new set of vital signs, cursorily reexamines the patient and writes another note dated the new day - gets credit for two days notes with only one visit.
3. Creative use of a ruler - I have seen a particular plastic surgeon do this. He measures a laceration he is fixing by putting the one end of the lac on the “1″cm mark of the ruler and then measures to the other end of the lac. If the other end is at 4cm, he calls the lac “4cm” when in fact it is really 3!
4. Excessively suturing a wound - some docs purposely put in an unnecessary deep suture or two in order to call it a “multilayer closure” which pays more than a single layer. (of course it is always debatable if that suture was needed so no one really every fusses unless a complication occurs which is rare)
5. Taking a patient to the OR too eagerly - many wounds, fractures, lacerations, etc can be managed in the ER with the right equipment. Many “surgical” problems can and should in many cases be managed conservatively (like a partial bowel obstruction) and should only go to the OR if conservative management fails. However some surgeons are consistently taking patients to the OR at the drop of a dime for “exploratory laparoscopy” or other procedures. Other examples are fixing simple tendon lacerations, “washing out wounds” - that are really not that dirty, and taking a patient to the OR for conscious sedation (which of course can be done in the ER in most cases). In many cases, I wonder how much of this is motivated by money and what insurance someone has - and as you will see below, if it comes from the ER it is an “emergency”.
6. Bringing in elective cases to the ER and then taking them for surgery - A very common practise. In fact, some surgeons who don’t take any insurance or are out of network, tell their patients to come in the ER in the morning at about 6:45 saying their problem (often a brain tumour or something else that was diagnosed a while ago) is not causing acute, severe symptoms - necessitating a trip to the OR. In fact, the patient is already booked on the OR schedule for 7:30am! This is done so that the doc get the full out of network payment - AND the patient is not responsible for any of it since it was an “emergency”. This is generally accepted in this day and age since patients often can’t afford an out of network surgical bill. This is also done in a similar fashion when a patient calls a plastic surgeon’s office and says they cut their forehead - he or she says to meet them in the ER instead of his or her office (even though they easily could do it there) so the surgeon gets paid fully and the patient only pays the ER copay instead of the surgeon’s entire bill.
7. Massive over-billing for procedures - Out of network docs can submit ANY bill they want to an insurance company. Of course they usually don’t get paid the entire amount but often 50,60, or 70% of it. (If they were in network, they would get a pathetically small amount on the other side of the coin). A perfect example is one I heard about - a neurosurgeon submitted a bill for an elective outpatient 4 hour back surgery. His bill 120,000.00$!!! He may walk away with 60K I think. Was it worth it? I would think not - but docs just often “throw stuff at the wall and see what sticks”. I doubt he will balance bill this patient for 50-70K ! If I were him, I would do three to four cases a year and call it a day!!!!
I am sure there are other ways of milking the system - committed by members of all fields (including mine). It is sad because a friend of mine who works for a health insurance company describes the whole health care industry in this way (which I think is true): Everyone is trying to f@$@ each other - the doctors try to f@%#$ the insurance companies, the hospitals try to f@%%@ the insurance companies and the patients, the insurance companies try to f@$$@ the patients, hospitals and doctors, the patients try to f@%$# the docs,hospitals and insurance companies and ad infinitum!
Remember again, I am not signaling out a particular field of doctors - most docs are ethical and just want to do what is right for patients and make a good living doing so. But of course there are always bad eggs…
Canadian Pharmacy
re #3: do plastics guys get paid more for a bigger lac? Why the creative measuring? When I sew someone up in the office (I’m a pediatrician) I’ve only ever discriminated between “simple” and “complex.” (I think, or maybe we’re not billing correctly.)
It is my understanding that length does matter for some insurances.
Back when I was working in hospital medicine, I saw something quite regularly: Specialist docs who had no idea who I was, would come into the patients room while I was doing something (ie ABG, central line removal, etc). They would look at an unresponsive/delirious patient from 5 feet away and walk out. They would then write a note with a complete physical exam.
Happened all the time.
Here’s a thought - report the abuse to the proper authorities. I am just stunned and amazed at how patients are made fun of and called names (my particular favorite “drug seeking”) in so many of these health profession blogs, yet these patients are the very people that end up in my law office. Oh, that drug seeking patient - well, she had adenomyosis - undiagnosed and labeled drug-seeking until severe anemia showed up. That drug-seeking migraine patient with the blind spots and severe headaches for several months - retinal artery stroke. And that drug-seeking uterine pain patient who was given valium because she was obviously just “hormonal and hysterical” - pelvic inflammatory disease. All three patients now have complications due to the attitude that seems to be just floating through the medical field. If it is a female and you can’t find anything on the lab tests, cat scans or MRI’s, then they are drug-seeking. Those very same drug-seekers are now in my hands with permanent disabilities. My thoughts to the medical profession - when a patient says they are in pain, they are in pain. It isn’t your body and pain is subjective. And sometimes, it is a zebra.
Sometimes drug seekers are just drug seekers.
The CPT codes for laceration repair go by length of the wound — in 2.5 cm increments. So upping the length from 3 to 4 cm won’t help you at all. But upping it from 2.4 cm to 2.6 cm, or from 4.5 cm to 5.1 cm will help you a lot!
Right Shadowfax. I was not sure of the actual length increments but I am sure the plastic surgeons do!
The ones that are labeled “drug seekers” are not patient’s that come in for pain meds once, or twice, or evern 3-10 times.
They are the ones that have had multiple workups done, not seen the doctors they were told to followup with, and still come back to the ER (4 times or more per month for years. THESE are the ones that are drug seekers.
Did the adenoymosis patient who probably had negative ER labs/ct’s….followup with the gynecologist for ongoing undetermined pelvic pain? Or decide to come to the ER 8 times in a month instead
Did the retinal artery stroke (I’m assuming you meant retinal artery occlusion) patient who had symptoms for MONTHS every see her PMD or a neurologist? This condition doesn’t “usually” cause headaches anyway. Also, treatment for this is for the most part futile if it’s been going for more than 2-12 hours. Months? MRI/LP would show any other dangerous things. If pt has persistant symptoms, they are told to followup with PMD and/or neurologist. When they don’t do that but still keep coming to the ER—They are a drug seeker.
PID patient: shouldn’t have “chronic pain”. Have pelvic pain. Get examined, get pelvic exam, get cultures done, maybe a sonogram. If cultures are negative and sono is fine. She doesn’t have PID or infection. Still having chronic pelvic pain. See your gynecologist. WHen she doesn’t but still keeps coming to the ER—drug seeker.
Just my thoughts.
(I am stunned and amazed at those who seem to have sympathy for drug seekers. Sure there are many many people that have real pain syndromes. Sure everyone has heard of a story of a “drug seeker” being “neglected” and having a bad outcome. One of the first things I leared in residency was “drug seekers get sick too”. I always think of that with EVERY single drug seeker—–but to be honest—-MOST of them are just seeking narcotics to get their high or to sell them. It’s an unfortunate truth to current day medicine.
How about doctors billing for not even being there at all?
I’ve been getting billed (originally typo’d as “bilked” which fits just as well) by a paediatrician who supposedly was present when my son was born 16 months ago. Problem is, 1. I was there and I don’t remember seeing him, 2. a different paediatrician, also on staff at that hospital, actually was following my son in hospital until he was discharged, and 3. unlike the doctor in item 2, the first doctor’s name appears nowhere in the chart… of course the insurance is refusing to pay for two paediatricians, as well they ought, so he’s coming to me for his $489. Now what?
As a migraneur for over ten years (and a medical student for one), I can personally attest to the frustration and embarrassment that comes with any trip to the ER. Nine times out of ten (well, four times out of five - I haven’t been in the ER ten times), the attending, resident, or PA seems to automatically operate under the assumption that I am drug-seeking. I can FEEL it. Typically, the provider will do the usual migraine work-up, then ask me either “What usually works for you?” or “What do you usually get?” Any specific answer will send up a red flag. I am a migraneur and a medical student; before med school I worked in two different primary care clinics, so I know the meds well. But as soon as I give them that I get the best results from a liter of saline with phernergan and either dilaudid or demerol, the eyebrow is inevitably raised. They ask the question and then are suspicious because I know the names of the medicines. I’ve had the Toradol-Benedryl-phenergan cocktail that everyone is so in love with these days and it doesn’t work. My last trip I told the PA this during the exam and he still ordered it. Then, when it didn’t work, just as I had told him it wouldn’t, he acted like he had never heard anything so preposterous.
The moral of my story is that not everyone is a drug-seeker, and operating under the assumption that every patient is compromises care and makes a patient who feels bad feel even worse. There is no question that there are drug-seekers who waste time and resources in the ER (or any other clinic); I’ve seen them and dealt with them myself. But treating everyone who walks through the door as a drug seeker is just an excuse for not doing your job. If you can’t spend five extra minutes figuring out who is and isn’t drug seeking, or if you can’t tell the difference, find a different job. There is plenty of money to be made doing hair transplants or giving rich folks Botox injections.
I’m well insured. In 2002 I took a helicopter ride to a big-city trauma center post motorcycle accident with a Schatzker VI Tibial Plateau Fx, which led to a quad-compartment fasciotomy and skin graft to close the medial incision. Internal and External fixation, etc.
Obviously, the surgeon who saved my leg also handled all of my follow-up care. Imagine my shock when the “out of network” bills came in for all the surgery, Not for anything else, just the surgery.
Apparently he had 2 different provider numbers, one “in network” and one out. He’d use the “out” one for expensive stuff when he didn’t want to accept the cut-rate from being “in network.”
I later learned that my wife had paid several thousand dollars of this while I was laid up. I raised 9 kinds of hell with the insurance company, and they later told me what he’d done, but I never did get back the $$ I was cheated out of.
I say “cheated” for a good reason… When he agreed to be “in network” he also agreed to accept their pay scale. To manipulate things as he did is fraud, or at least breach of contract. He was listed by name and address as “in network” yet billing “out of network” when it pleased/profited him to do so. Fraud.
Further, he never informed me of this until the bills were sent — until I got the bills I was under the impression all of it was “in network.”
I am grateful — he really did save my leg when a lesser Doc may have ended up amputating it. This is the only reason I didn’t sue him over his fraud. As it is, I know he won’t be doing this to anyone else, and I’ve been lucky enough to find another, more honest surgeon.
I’m also willing (eager, actually) to be educated, so if I have misread any of this please let me know.
Thanks!
Alan
Oh, one more…
I spent several weeks in a “rehab center” after leaving the hospital. I got billed $1,600 from a psych Dr. affiliated with the rehab center who never saw me. The bills from the “rehab Doc” who came 2x/week but billed daily were bad enough, but this one I fought. Ended up having to pay it.
All told, even though I had a top-tier BCBS insurance plan, I was out of pocket to the tune of about $40k for that accident by the time all parties got their piece.
This, added to lost wages, was the biggest reason I was forced back to work (AMA) after only 5 weeks of the 6-12 MONTHS I was told to expect for a rehab period. I simply had no choice.
Reading about all these deadbeats just makes my blood boil, because I know most of “my expenses” really went to cover the costs incurred by people who abuse the system.
DD
Wow dedicated_dad, that is a sad story. The first situation with the surgeon with two ID’s is absolute fraud and he should be fined and professionally reprimanded by the state licensing board. The other things are unfortunately just commonplace and sad. I think however you could get back that money from the psychyiatrist who never saw you! Also, I have found that most doc’s won’t balance bill you the entire amount (when you are out of network that is) if you work something out with them. Plus, most of this stuff was emergent and in the hospital so your insurance company should not charge you more than your deductible/copay. The rehab probably was out of network however and not “emergent” so you would probably have to pay that bill.
Thank you Terri! And as for “Did the retinal artery stroke (I’m assuming you meant retinal artery occlusion) patient who had symptoms for MONTHS every see her PMD or a neurologist?”
Not everyone has a nice paying job and/or insurance and when we don’t have one or both, are refused to be seen by anyone EXCEPT THE ER!!! When that changes and doctors have to actually, oh my gosh, DO THEIR JOBS WITHOUT WORRYING ONLY ABOUT THE ALMIGHTY, F$%^ING DOLLAR, THIS WILL CHANGE!!!
Stop assuming just because you can’t find the problem that it is all in the person’s head, especially when that person is female. Maybe you’re just a shitty doctor!
This is for EE from Backboards & Bandaids - Kiss mine! Because I already know what kind of stupid, snide comment you’re going to make. You’re a conceited little punk that shouldn’t be allowed to care for anyone until you grow up!