Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Friday, January 19, 2007

Referral, Referral; Who's Got the Referral?

I love Medical Economics. I have been a devoted reader ever since residency. Not only did I find it fascinating enough to read cover to cover, but in those first few years I occasionally found checks (made out to cash, with no fancy fine print below the endorsment line committing me to three years of credit protection) tucked somewhere in the back. I didn't recognize the shameless marketing tactic back then, but I would have read the magazine anyway. I still devour each issue, though I now often skip over the finance articles. It's too depressing to read about stocks and mutual funds when I can barely pay myself.

One of their features is a column called Malpractice Consult; an advice column written by a malpractice attorney. After all these years their answers kind of blend into a general refrain of "document out your ass." I get it. I do it (mostly.) Because I began reading MedEc so early in my career, I've been running scared from the git go, so it's taken me a while to relax a bit and realize that although anyone could sue me, most people probably won't. The lawyers' chorus bleating "You Never Know," while technically accurate, has begun to feel like just a scare tactic, reinforced by the benign outcome of my single malpractice suit.

Malpractice Consult has taught me that I'm responsible for a lot of things related to medical care (which also need to be documented out my ass.) Suits have been brought for "Negligent Prescribing"; I need to explain the what-when-why and potential adverse effects of every single prescription I write. Suits have been brought for "Failure to Diagnose"; I'm supposed to document my thinking about every diagnosis I consider, what I did to rule it out or why I decided not to -- for every patient's every problem, every time. And suits have been brought for "Negligent Referral."

Not just "Failure to Refer in a Timely Fashion", "Inappropriate Referral" (to the wrong kind of specialist) but "Negligent Referral": sending someone to someone else who screws up. Apparently it is also my responsibility to keep tabs on the quality of care (per Dr. Bob, a simple, easily implemented concept) provided by the consultants I recommend.

Ok. Fine. I get the idea. Frankly, though, the only means available to me to express any dissatisfaction I may have with any given specialist is to withhold future referrals. But sometimes even that isn't enough.

I have three local options for ENT referral: a solo and a 2-person practice that I like very much, and another 2-man practice that I don't like. Not because they're younger/newer, but because I don't trust them. Why? For starters, the letters they send me always document a full head and neck exam on every patient, even when some maneuvers were clearly not done. (How do you perform a Rinne or Weber test on a two-year-old? And why would it be necessary when he's being referred for nosebleeds?) They write "Thank you for your referral" on self-referred patients, presumably so they can bill the visit as a "Consult" instead of as a much less lucrative "evaluation and management" visit. Other patients have confirmed that documented procedures weren't actually done. Another patient who met the senior guy in the hospital (where I have no control over the admitting doc's referrals, as I'm not on staff there) told me he was a "cocky little bastard." Suffice it to say, I don't refer to them.

However twice on recent occasions, imagine my surprise when patients went there instead of to the office I recommended (and documented.) Although awkward, I asked them why, and got answers like "Well, my dad goes there so I thought I'd try them." So much for my considered medical judgement about consultants. What could I say?

I'm not really worried about the lawsuit angle, because I've clearly documented that my referral was to A and not CLB. But the guy gave a toddler double the recommended dose of an antibiotic (and gave me lip when I called -- politely -- to point out his error) and then sent the kid for an infectious disease consult for a non-condition I had been explaining to the parents for weeks. She did fine with the tonsillectomy, but geez; what's a poor dinosaur to do?

I suppose I could refer you...


At Fri Jan 19, 07:35:00 PM, Anonymous Anonymous said...

I've been waiting for this subject to come up.

Why do some specialists 'pad' their reports with superficial or even fictitious statements? Statements as you mentioned above, about performing certain physical tests, when the tests weren't done. Or embellishing what they say they explained to a patient. Are these specialists trying to impress the primary care doctor with their 'thoroughness', so as to keep the referrals coming? Are they trying to make themselves look better than their fellow collegues? Or are they simply filling out a quasi 'form letter' report, which is just slightly individualized for each patient?

I always make certain to get a copy of my own specialist reports, and I'd say ~70-80% are quite accurate in describing what took place during my visits. Then there's the remaining specialist reports, in which I have a rather different recollection of what took place. Interestingly, it is often the specialists who have spent the least amount of time with me, who write the longest reports, full of the grandiose statements of their clinical thoroughness.

This would all be in good fun, except these padded reports make it difficult to discuss my health concerns with my family doctor. My doctor is getting one story from the specialist, and hearing something different from me, leaving my doctor in the middle, trying to figure out what is going on.

At Fri Jan 19, 09:05:00 PM, Anonymous Anonymous said...

I love your blog, Dr. Dino. I'm not a doctor myself (altho' I have a couple of siblings who are) but I've always been interested in Medical Economics (did my college thesis on a topic in that area). It's so cool to learn what a Dinosaur aka Family Practice Doctor really does from day to day -- I always had just a vague sense of it, and it's impressive to get a glimpse into what really goes on. I enjoy your writing style, linksmanship, & sense of humor too. -- A Fan from Kensington MD

At Sat Jan 20, 11:05:00 AM, Blogger lucia said...

so tell me Dr. Dino, really do you doctors care or mind when a patient presents with an attorney mom? we attorney moms can't help but be a complete pain in the ass. any advice? any thoughts on why doctors and lawyers have such distinctly and differently wired brains? p.s. attorney moms know that true malpractice actions requires an extreme "oh my god" sort of mistake and, thus, we would probably be the last to chase down an ambulance with your name on it.

At Sat Jan 20, 06:50:00 PM, Blogger Big Lebowski Store said...

Wait a sec, if you see patient in consultation, how can you bill an E&M code? It's not your patient! I see patients in consultation all the time (I do pedie pulm as a side-line). The other day I did what was essentially a sick visit (the patient of an FP colleague of mine insisted they be seen on a day I had no time for a full consult). Should I have billed an E/M code instead of a consult code?

Finally, I don't pad, and my EMR forces me to code honestly. I find it virtually impossible to code a consult at higher than a level 3. In fact, I've never done it.



At Wed Jan 24, 05:56:00 PM, Anonymous Anonymous said...

Any patients who see write-up's for services that didn't happen should let their insurance company know immediately. Not only does the insurance payment go up when fraudulent services are billed, but depending on the plan the patient may also be paying more (due to coinsurance).

Another reason to complain is that medical records are official documentation. If an MD writes a report and says a service was done, that becomes part of the patients PERMANENT record. It is up to patients and doctors to make sure those permanent records are as accurate as possible.

Not to mention upcoding is just plain fraud, fraud, fraud.


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