Dr. Hospitalist: Improper, Aggressive Billing Raises Ethical, Legal Concerns

Dear Dr. Hospitalist:

I am a seasoned hospitalist at a large academic medical center in the Northeast and have recently become more bothered by how our group is being coerced to aggressively bill for our services. It seems the current reimbursement environment has pushed some of our leaders to demand more aggressive billing from our hospitalists. How should I respond?


A Seasoned Hospitalist

Dr. Hospitalist responds:

By “aggressive billing,” I assume you mean billing that may not be entirely ethical and approaching or outright fraudulent. The short answer is you should always bill only for the services you perform. I know—if only it was that simple.

As another “seasoned” hospitalist, I, too, have seen the wide pendulum swing from when internist inpatient billing was an afterthought and done by others to the current system of billing classes, RVU enticement, and reminders of how to construct the note. Enter the electronic health record, and now instead of clinical notes being used as a form of communication among clinicians, it does seem today to be created more for billing purposes.

How did we get here?

Physicians have to accept some of the blame. I can recall when I was an orderly at our local hospital in the mid 1970s and some physician “rounds” consisted of standing in a patient’s doorway and calling out, “How are you doing today, Mrs. Smith?” I must admit to having no idea how these docs were billing, but I do know that Medicare allowed for twice-daily billing for hospital visits back then. I also recall some of the paltry progress notes that consisted of one-liners like “pt doing well today.”

Like most corrective actions, the response has overshot the intended mark and made the daily progress note more ritualistic than informative. When the first attempts by the American Medical Association and the Centers for Medicare & Medicaid Services were released in the early 1990s, I’m sure most docs had no idea it would morph into its current level of significance for reimbursement—and that one day docs would be asked to implement, keep up with changes and modifications (think ICD-10), and use daily. Don’t get me wrong: I, like most hospitalists, recognize the clinical utility of a concise and well-written note. But when an otherwise complete H&P gets down-coded from a level 99223 to a 99221 because I leave off the family history of a 95-year-old man, of course I believe something is wrong with the system.

Also, human nature being what it is, I have always felt that if you incentivize people to increase production of an item, whether it’s a widget or an RVU, you will have some who will learn to game the system, consciously or subconsciously. With healthcare spending in the U.S. approaching 20% of gross domestic product, we as physicians should not be placed in positions of increased financial gain at the expense of our country’s economic health and viability. After all, we’re citizens first and physicians second.

You should recognize the need for proper coding and billing as inherent to the hospital’s financial viability, and if done correctly, it should not create an ethical or legal conflict for you. In the vast majority of cases, a well-written note can be properly billed and coded without creating angst.

Good luck! TH

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