10. The Signature of a Professional…


Until recently I was a member of an on-line discussion among something more than a thousand psychiatrists.  The subject of insurance company audits of medical information arose.  A colleague said,

I never was in the habit of keeping much written about psychotherapy sessions.  I was in school when Nixon’s gang stole notes out of Ellsberg’s psychiatrist’s office. I decided then that I would never write much about what a patient said.

This produced a response from a second psychiatrist who said,

Privately, it will be a cold day in hell before any third party “audits” my psychotherapy notes – or I write notes to confirm to idiotic billing codes. I’d rather dig ditches. I don’t accept any insurance, which is unfortunate, but at some point you become co-dependent to ingraining corruption rather than helping your patients. I would rather see patient’s low-fee or pro-bono on my terms.  …  

 I just got dressed down for including in my charting that IMO, a patient was being discharged prematurely due to insurance denial and hospital pressure.  I don’t give a damn if the administration doesn’t like it. [Ed. A false discharge rationale] is not going into the records over my signature.    … The buck has to stop somewhere – and if we leave it to the third parties, we’re all screwed.
This exchange provoked a number of recollections from my own practice of conflicts between medical and administrative imperatives.

A cautionary tale…There was once a card player named Scarne, so skilled in all the sight-of-hand tricks with cards that, although he didn’t cheat at cards, he was banned from play in virtually every casino.Since he knew every trick, he could also spot a cheat that others could not detect. He wrote a book called, “Scarne on Cards”, in which he offered this advice: Paraphrasing, if you realize that you are in a crooked game, or spot someone cheating, don’t say a word. Professional gamblers, he warned, could not allow a cheating accusation to stand unchallenged, and you might well lose your life in whatever fight ensued.  Instead he advised that you quietly fold your hand and, accepting your losses, simply leave the game at the first opportunity and walk away.

Back in the late seventies I, as an honest family practitioner, found myself in a crooked game called Medicare. I did walk away, but not entirely quietly.

Although in solo practice, I did share emergency night and weekend call with three colleagues to lessen the burden. We still took call for all our own hospital and nursing home patients. In my experience, nursing home emergencies were usually the result of long-overlooked conditions that could and should have been caught much earlier, and that suddenly became emergent when severe signs were noticed by the midnight shift of nurses at two in the morning. I had never had more than a couple of patients in nursing homes so was not much troubled by this dysfunctional pattern.

However, when a colleague quit practice and joined the Army, he begged me to take on his nursing home patients, numbering about a hundred. I resisted for a few days but finally thought of a way to do it right. Medicare would pay for one routine visit a month per patient, which I thought was not often enough to prevent the development of midnight crises, but I reasoned that if I, and my hospital-experienced office R.N. officially made rounds together on half the patients every two weeks, we would maintain frequent unofficial contact with all of them, and with the nursing home staffs as well.  Premonitory signs would likely be seen by us or mentioned to us while on rounds, largely avoiding the 2 a.m. emergency scenario.

It went very well and just as predicted. Since all were new patients to me, some required longer visits during the first couple of months. The billing went in every two weeks.

The Medicare fiscal intermediary, (the insurance company contracted to process Medicare payments), had a 90-day lag in payments, so in the third month my bookkeeper came to me aghast, with the news that Medicare had downgraded ALL of my billing codes, e.g. from “routine” to “brief” visits, and the actual income had been reduced to something far less than anticipated. To wit: the income did not nearly cover the expense of having me and my nurse out of the office for nearly a full day every other week.

We appealed and were stonewalled.

It was at that point that I became aware of similar stories circulating in the medical community.   Medicaid insurers were discovered to have removed the authorization stickers from claims submitted and, as a stall, had returned them stamped “No Sticker” to physicians offices.  Having already submitted the stickers, the doctors had no others with which to re-submit the claim.  They were caught when one suspicious doc photocopied all his claims before submission — with stickers.  In another case an insurance employee was fired for being intoxicated at work and was found to have filled the bottom drawers of his desk with unprocessed claims, where he habitually stashed the forms when he got behind in his work.

I wrote a form letter explaining the Medicare situation and sent a copy to the families of each of my nursing home patients, telling them that, allowing a reasonable period of time for them to find another physician, I would no longer be able to care for their respective relatives.

To the letter I added the names and direct phone numbers of the regional director of the Social Security Administrator and the department head of the fiscal intermediary, Blue Cross at the time as best I recall. Thus, I did not leave quite as quietly as Scarne recommended, but I left.

What is a Good Medical Record ? …

In family medicine, occupational medicine and on the forensic unit of a state mental hospital, and based upon a couple of years of law school and the giving on several occasions of testimony in court and at depositions, I found that very complete and legible records served me best. My records were not what I would call self-serving, but whenever I wrote in a chart I was certainly aware that I might someday be asked to read my notes out in court.  I was careful not to write anything that was flippant or disrespectful.   In my occupational medicine years when, for instance, a patient was irate at being sent to my office by a manager, my notes were carefully detailed.

Working at the state hospital after my psych residency I took my own laptop in to work. With Microsoft Word, and using the standard templates for hand-writing psych histories, monthly notes, and monthly orders on paper, I was able to reduce the time for doing monthly notes and orders on my patients from and average of 17 full days per month, to just under one day. Nothing was ever omitted, the record was printed, therefore readable, and the background history was repeated each month, and therefore, being part of the current monthly note, was not susceptible to the culling of “outdated” materials every 90 days, a practice I had discovered, that had caused much crucial background information to be lost from patient charts over the years. (State hospital patients typically remained in the hospital for decades, and earlier information wound up in a stack of records four feet high in the record room, but not available in the chart on the patient’s ward.)

Because my computer notes, were complete with meds, responses, side effects and a current status paragraph, they also fulfilled the requirements for all the other common summaries. A discharge summary, readmission note, or transfer summary could be produced simply by changing the title of the first page.

The hospital Record Librarian at first tried to claim my computerized records did not meet the record-keeping requirements of the Joint Commission on Accreditation of Hospitals (JCAH) and would be rejected because they were “canned”. She asserted that the JCAH would forbid monthly notes of which a copy could be produced automatically from month to month without actually reviewing or describing the patient’s actual status. However, indulging a habit formed during my law school training, I had personally read the JCAH rules rather than taking the word of others regarding their content. Therefore I knew that my system met not only the letter, but the spirit and intent of JCAH requirements, especially regarding clarity, completeness and legibility. And the ‘current status” section included discussion of any changes since the previous note. When they, and later the Hospital Medical Director called to tell me to cease and desist computerizing my patient histories and notes, I told them I’d do so as soon as they showed me the JCAH rule that forbade my system. They never called back.  This was in the early 1990’s and now, of course, the electronic health record (EHR) is becoming the standard of care.

I know that corporations (including insurance companies) are the perfect group analog of an individual sociopath or psychopath, and government agencies can be thugs, so I could be wrong about this. But I have always believed that if you do the right thing, and then clearly record that you did the right thing, you are going to be OK. On the other hand, all of my private practice years were in general medicine. I have never had to be responsible for guarding the privacy of private psychiatric records, because I practiced psychiatry on the forensic unit of a state mental hospital, where the presence of the patient was a matter of public court records, as were my periodic recommendations to the court.

In an environment where computer information is routinely hacked, with the loss of the private information of millions of people, perhaps my habit of recording everything in detail is in need of review.