Must Have IV & Monitor "Because Management Said So"

[engine173351]

Last year, I began working as a part-time paramedic for a medium-sized ALS service that primarily conducts dialysis and non-emergency interfacility transports, as well as emergency transports for SNFs and nursing homes. The service is fairly standard in terms of setup, with updated equipment and protocols, and is one of the larger services in the area.

After I had been on the job for a few months, the service's QA/QI person (who reviews every patient care report submitted) sent out a service-wide memo warning all paramedics to "act to their level" when treating patients, and that all patients being transported to an emergency department - regardless of their condition - absolutely need to have a monitor connected and an IV established. A few weeks after that, I transported a patient from a local nursing home to the emergency department for a possible fracture of the thumb secondary to accidentally closing a door on it. In my judgement, that patient did not require a monitor or an IV. The following day, the QA/QI person approached me and cautioned again that all ED patients must have an IV and a monitor.

The dilemma here is that management is stripping paramedics of their clinical judgement when it comes to interventions. I am aware of upcoding/upbilling in the reimbursement process, and am not sure of this situation would constitute that. What would you do and how would you approach this?

[paramedicmike]

There are a few questions here.  What is their mindset requiring an IV and monitor?  What is their justification?  Is your medical director on board?  What does your medical director have to say about this?  What answer were you given when you questioned why a suspected thumb fracture needed an IV and monitor?

Knowing whether this constitutes upcoding and/or fraud will depend on their billing practices.  Based only on what you've provided so far I don't think it's a straight forward answer.  You can always contact CMS and ask. 

If this is something you're legitimately concerned about then quit and find a new PT gig.  Take steps to protect yourself.  Document everything.

Keep us posted.

[Off Label]

There are a few questions here.  What is their mindset requiring an IV and monitor?  What is their justification?  Is your medical director on board?  What does your medical director have to say about this?  What answer were you given when you questioned why a suspected thumb fracture needed an IV and monitor?

Knowing whether this constitutes upcoding and/or fraud will depend on their billing practices.  Based only on what you've provided so far I don't think it's a straight forward answer.  You can always contact CMS and ask. 

If this is something you're legitimately concerned about then quit and find a new PT gig.  Take steps to protect yourself.  Document everything.

Keep us posted.

Last year, I began working as a part-time paramedic for a medium-sized ALS service that primarily conducts dialysis and non-emergency interfacility transports, as well as emergency transports for SNFs and nursing homes. The service is fairly standard in terms of setup, with updated equipment and protocols, and is one of the larger services in the area.

After I had been on the job for a few months, the service's QA/QI person (who reviews every patient care report submitted) sent out a service-wide memo warning all paramedics to "act to their level" when treating patients, and that all patients being transported to an emergency department - regardless of their condition - absolutely need to have a monitor connected and an IV established. A few weeks after that, I transported a patient from a local nursing home to the emergency department for a possible fracture of the thumb secondary to accidentally closing a door on it. In my judgement, that patient did not require a monitor or an IV. The following day, the QA/QI person approached me and cautioned again that all ED patients must have an IV and a monitor.

The dilemma here is that management is stripping paramedics of their clinical judgement when it comes to interventions. I am aware of upcoding/upbilling in the reimbursement process, and am not sure of this situation would constitute that. What would you do and how would you approach this?

I'd defer to county ALS protocol, but I'm guessing you didn't need someone to tell you that. As to checking with CMS for fraudulent billing and "up coding", be sure that your initial inquiries are anonymous. If it is Medicare fraud, investigators have not been very picky whom they implicate in terms  direct or indirect participation in fraud. Not to sound overly dramatic, but look into whistle blower protection to cover yourself in the off chance things go sideways.

[Just Plain Ruff]

Man, what is the medical necessity of putting a monitor on a thumb fracture?  what is the medical necessity of putting a iv in a patient with a isolated thumb fracture?  How do you justify the need for both in a "Isolated thumb fracture" and how do you write it in your report to justify it to medicare and medicaid or even any private insurance company.  Or even how would you justify it to a person who had no insurance?   You can't and your company can not either.  

I remember way back when, when AMR came into my coverage area and took over our service.  They forced us to write in our reports that the patient was bedridden and needed to be assisted to our cot via 2 man lift and then the same when we put them onto the ER bed or Nursing home bed.  If we didn't do this for both trips we would be called into the supervisors office to re-write the report to make it "billable" for medicare/medicaid even if we had already given the nursing home or hospital our original report.  If we refused we were threatened with suspension or even termination.  The reports had to be written this way even for patients who could walk to our cot or who could move themselves to our cots.  

I took a stand and told them NO, I would not rewrite my reports and they tried to suspend me.  I told them if they did that, I would call medicare(CMS) and ask them if this practice was legal or ethical.  They backed down and soon stopped requiring us doing this on every patient except the ones who were truly bedbound as I believe they truly knew that this was fraud.  Unfortunately, I left the service soon after under not so great circumstances, not sure if that is what was the catalyst but it was for the best. Career wise for me at least.  

 

[ERDoc]

Don't mess with CMS.  They will screw you and are looking for fraud.  It may take them a while, but they will find it.  A CMS audit is no joke.  CYA, get this stuff in writting and think about whistle blower protection.  As an aside, if you brought this thumb fx into the ER with an IV and monitor I would have something to say about it.

[Just Plain Ruff]

Don't mess with CMS.  They will screw you and are looking for fraud.  It may take them a while, but they will find it.  A CMS audit is no joke.  CYA, get this stuff in writting and think about whistle blower protection.  As an aside, if you brought this thumb fx into the ER with an IV and monitor I would have something to say about it.

Exactly,  I can't imagine any ED physician who would not say something to a provider who would start an IV and put a monitor on a patient with an isolated thumb fracture.  And the minute you told that physician that "it's protocol" or "I'm supposed to according to our firms rules" you would probably be the butt of many a joke.  

 

a simple anonymous call to the CMS office in your area, you can get the number via a simple google search would put a bug in any CMS investigator's ear.  

Doc, just how would one go about getting whistleblower protection?  Would that be based on the first one to make the call "non-anonymously" to CMS?  

 

[ERDoc]

I have no idea, I just know what I have heard.  That is probably a question is ask CMS or maybe google.  I also know that there is a reward (I think it is a certain percent) for any fraud that is turned in.

[Just Plain Ruff]

I already know about the reward,  I have a good friend who is now a very rich person based on his whistleblower to the office of civil rights based on his report against his employer and what they uncovered.   For every violation (10K) that they levied, he received 10% of that fine.  They levied 5000 violations.  you do the math.  He owns a nice little horse ranch outside lexington kentucky.  He didn't receive the entire amount but he did receive a hefty chunk.  Plus it ended up costing about 25 people their jobs.  Pretty big deal.  It was not EMS related though but it was health care related.  

I've been to his ranch and I've ridden his horses, talk about green pastures.  He made out pretty well.  

[rock_shoes]

Tossing on a few monitor leads and taking a set of vitals? No big deal even if it isn't particularly relevant to the patient's complaint. Starting an IV without any clinical indication just because management said so? Big problem. That's an unjustified invasive procedure which, though pretty routine for most of us, is not without risk.

 

Now as to the billing side of things, I don't fully understand the relevance. I work in a provincial system. The bill is the same ($85) heavily subsidized amount whether the patient is a 5 minute transport for a stubbed toe or air lifted. Do US services charge by procedure (ie. basic transport fee plus $15 for the IV, $20 for patient monitoring, $300 for an ET tube...)?

[Just Plain Ruff]

well It's been a while for me, but we used to fill out charge forms.  150 for transport fees,  Iv STart charge, Iv fluids fee, monitor charge, ET fee etc etc  and yes, the patient is charged for all that individually.  So that is definately the issue here.