Having pretty much wrapped up their investigations into ICD malfeasance amongst implanters (OMG, this ICD was implanted only 89 days following a stent!!), the Department of Justice (DOJ) is probably casting around to find the next bushel of low-lying fruit. Here are some suggestions for future investigations. (Disclaimer: my lawyers advise me to state emphatically that I personally have never been involved in any of these scams).
Fake pre-operative H&P updates. The patient is draped and on the table. You are about to scrub in, when somebody notices that the H&P you did from the office is 31 days old (even accounting for leap years). Rather than undrape or contaminate the sterile field with your stethoscope, you rapidly fill out the H&P update form by copying from the ancient office H&P. Later, after the procedure, you find to your horror that the patient, unbeknownst to you, had undergone a heart transplant in the month since the office visit, and didn’t actually need that defibrillator after all! That will teach you to fake the pre-op H&P! This is of course an extreme example. Nevertheless, if the DOJ could determine a fool-proof method to determine a pre-op H&P was faked, this could yield a virtual gold mine in fines and go a long way towards paying off the national debt.
Copying and pasting electronic health records. Copying and pasting is probably the ultimate form of laziness. In the days of hand-written medical records, we had to laboriously write out or dictate our history, physical, assessment and plans. It took some creativity. With electronic health records (EHRs) this is no longer necessary. In fact, in the EHR we use, there is a button to import the whole last patient note into a new note. Assuming not much has changed, one just tweaks the old note and, voila!, a brand new progress note in less time than it takes for a high school student to plagiarize a report from Wikipedia. The new note has all the frills, bells, and whistles that the coders like to see, so that you can charge a Level 5 visit for what only took a Level 1 amount of effort. This is another situation ripe with to possibility of heavy fines from the DOJ. Five identical notes in a row might be a good threshold to raise the red flag here.
Review of systems bloat. The review of systems (ROS) is definitely the most painful part of the History and Physical. Why can’t the patient fill out a check list for each encounter, or at most have the hospitalist or internist run through the ROS and that be the end of it? Why is every specialist expected to do a repeat ROS as if one per patient per hospitalization isn’t enough? Why do I as an electrophysiologist especially care if I am evaluating a patient for an ICD implantation whether the patient has seasonal allergies or dyspareunia? I mean, other than the fact that we lose points and therefore reimbursement if we forget to document that we asked these questions? So I fear that there are some practioners that might, shall we say, exaggerate the number of organ systems they have reviewed? The DOJ could make a killing going after those who claim they did a 12-point ROS when in fact they only touched on 11 organ systems.
EHR template madness. Filling out the discharge summary in our EHR system is made easy by the presence of a ready made template in which we just have to fill in the blanks. One blank is labeled “Discharge Exam.” Clicking on this, there is the option to automatically fill in a normal adult exam. Too easy! Until you notice, months later, that the exam that gets filled in automatically includes the statements “Rectal exam: normal” and “Pelvic exam: normal.” Now you are in the unpleasant position of either being overly familiar with your patients on the day of discharge (“Why did you see fit to perform a pelvic exam on your patient the day after her pacemaker implantation, doctor?”) or being stupid enough to click on a link in your EHR without reading what it inserted into the medical record. This one is a no-brainer for the DOJ. Just look for those discharge summary physicals with rectal and pelvic exams. Fraud or sexual harassment, they’ve got you either way.
So those are just some suggestions for further DOJ investigations that are likely to be lucrative. I would just like to say that I would be happy to volunteer to help in these investigations, provided of course that I was granted immunity first.