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Friday, June 28, 2013

Is what we do Medical Fraud?

This is a guest post from our RRT friend Will Lessons.

Sometimes I wonder if some of the stuff we do in hospitals is even legal.  Certainly I'm not a lawyer, and certainly I don't know everything about how to run a hospital, and I especially don't understand Obamacare.  Yet, still, some of the things we do seem to lean on the side of medical fraud. 

I will attempt here not to cross the line that will get me into trouble.  There are protocols and order sets that make it so, that in order to meet reimbursement criteria, or admitting criteria, certain things are automatically ordered for all patients.  Did you know that?  Is it that way where you work?

For instance, every patient, or just about all of them, are automatically given an IV.  You can go to your doctor's office with a cold and walk out hole free.  But if you go to the ER chances are pretty good you'll have a needle in your arm (or at least a hep lock).  The reason for this is that most insurance companies, and the government, believe if a person isn't sick enough to need a needle, he wasn't sick enough to be admitted.  So putting one in every patient is the best way of making sure you cover this base.

The same is true of lab draws.  "If the patient didn't need his labs drawn, why was he admitted?" an insurance agent may ask.  So to cover this base everyone gets lab draws, even that baby. 

Smoking cessation is well reimbursed, so every patient gets smoking cessation.  Is this legal.  Is it right to bill patients who don't smoke, and never have, smoking cessation?  Is it legal? 

Breathing treatments are automatically ordered, at some hospitals, for all pneumonia patients because if the patient is sick enough to need treatments, he must be sick enough to be admitted.  There are some admissions that didn't meet criteria because we didn't do enough (even though what was done was what was needed), so reimbursement was denied.  To prevent this, all pneumonia patients get albuterol whether they need it or not (and they get it four times a day). 

I mean, I don't know if what we do is medical fraud, yet sometimes I can't help wondering.  Is it fraud to give a breathing treatment to a patient in heart failure? Is it medical fraud to give a breathing treatment for a person who has laryngospasm? Is it medical fraud to give treatments to all RSV kids when studies show this isn't necessary for most RSV kids? 

See what I mean?  Is what we do Medical Fraud?


Note: The opinions of Will Lessons may or may not be the view of the author of this blog. 


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