Here’s why you wait in the ER

All have to wait. As is normal with all the busy ER, the ambient sounds of machines, alarms ringing, debilitating moaning, and loudly drunken outbursts permeate the section. It is a controlled insanity.

But, a girl’s scream pierced my spirit. Her baby eight-month-old boy put back in her arms. He is already pale, lips his torso not climbing as it must with breathing — that he is not reacting at all. We wasted no more time. Nothing brings help quicker to a room than a dead kid. We rapidly put a breathing tube, then started pushing on his small chest with our hands to help keep his heart beating, then drilled an IV to his bones, and pushed into all the drugs we could. Ten minutes passed. Nothing. Twenty minutes passed. Still nothing. For every other patient, we might assess heart motion and if it’s not moving, pronounce the time of passing. Not for children. Never for Kids. We spent 45 minutes for this baby. Helpless, the time had finally arrived. We were in agreement. Time of departure: 0205.

The heartbreak isn’t over though. Next is the mother. What would you say? Not much. I could just sit and try to absorb her despair, her skepticism — her remorse.

What’s next? We move on. It’s a hectic night… the damage had ripped into me, but I had more hours to operate; patients are awaiting. The next patient was waiting for two hours. I took a pause, massaging sanitizer involving my cold hands a couple of seconds longer than normal to compose myself. What occurred following etched into my head as far as the tragedy that happened minutes ago.

The patient berated me. Yelled at me personally. “I’ve been waiting for hours to see the doctor! What type of place is that!? You are supposed to treat me, not leave me waiting! I knew I should I’ve gone someplace else!”

Never have I felt this way.

“I’m sorry for your wait. It’s been busy,” was all that I could muster.

Maybe, if this person knew what had happened, there could be some comprehension — when the doctor has not talked to you yet, there is somebody sicker needing attention.

But we can’t say . I can’t say a kid has just expired. I can’t tell you that a seven-year-old girl’s figure, was ripped by a stray bullet. I can not mention that we just consoled a weeping family. I can not.

Our fast-paced culture needs convenience — click on a button to arrange clothes, instantaneous posts on Twitter, receive a hamburger by means of a car window. That which we’ve lost, however, is a tiny comprehension of the human condition — compassion for others. Sometimes we are so excruciating, we can’t see past our own hospital gurney. Nowhere is that more evident than the ER.

Triage must occur. With limited, exhaustible resources we must do what emergency departments are made for: take care of the sickest first. There’s a saying in medicine:”Vitals signs are essential.” That is where we begin.

By way of example, two patients require evaluation.

One is really a 30-year-old man with stomach pain with normal vitals — waiting hours.

The next is a 60-year-old lady with chest pain, quick heartbeat, low blood pressure — waiting ten minutes.

Who’s first? The choice is obvious. Without emergent therapy, patient 2 will perish quickly. Patients #1 might need to wait longer, but patient #2 doesn’t have this luxury. ER physicians will make this choice every single time without hesitation.

We are responsible for the whole ER, its people, and its finite resources. It does not matter who you are, the ER is the excellent equalizer.

For all our patients, we recognize this is among the worst days of their life. We try to deal with it like that. Regrettably, at the ER, somebody else is constantly sicker than you personally.

Admittedly, there are more factors beyond doctor management. The flow of this ER is much like this a five-lane freeway. When everybody goes the exact same rate, traffic flows nicely. When rush hour hits, more automobiles merge in the on-ramps and visitors slows. The ER also slows only by sheer volume. In case a semi-truck crashes, automobiles come to a stop before that truck is cared for. Likewise, we must tend to that gunshot wound to the chest before focusing on the others. The truck must be cleared to permit others to pass. When the destination is outside of parking areas, individuals are left unattended around the freeway. After the hospital is complete, the ER becomes crowded. The patients which need to stay in the clinic? We keep them at the ER, there is nowhere else.

No one likes excuses. If it was possible, we’d evaluate everybody instantaneously. Waiting kills. We know this. That’s why we are constantly developing methods to improve wait times. We’ve placed doctors in the waiting room, acquired blood work and X-rays straight away, streamlined workflow with different specialties and generated different areas to view less critical complaints.

Yet, it is insufficient. Folks will wait. People have emergencies. Doctors fill up. It’s sometimes tough to wear a different patient’s gown and step into their slippers, particularly when we are hurting ourselves. But that is what makes us human — why we appreciate society. As soon as we view a fiery crash on the freeway we expect that nobody is hurt and there are survivors. We understand why we need to stop our automobiles. Our basic instinct would be to wish the best for people.

The ER is an overwhelming place — especially for patients. Several factors contribute to the wait time — many supporting the ER doors, beyond our control and beyond our patients’ sight. We might be in pain and we all might be in need, but our empathy for our humanity can make it more tolerable.

How to respond to a Medicare audit: 17 tips from a lawyer

Although you may speak of a “routine” Medicare audit, there is really no such creature. This is like saying you have a “routine IRS audit.” The fact is that there is some item you have claimed as a Medicare provider or the amount of claims Medicare has paid in a certain category that has caused you or your practice to be audited.

Having too many claims for level five CPT codes might, for example, cause you to be audited. Having multiple claims submitted for the same date of service, may cause you to be audited. Submitting claims for CPT codes outside of your medical speciality area, might cause you to be audited. Having the dollar amount of claims greater than the average for a similar health practitioner in the same geographic area of the country, may cause you to get audited. Having a greater number of claims submitted than the average for a similar health practitioner in the same geographic area of the country, may cause you to get audited. Filing claims for services that are on the Office of Inspector General’s (OIG) annual work list may cause you to be audited.

“Routine” audits, those that do not involve some suspicion of false billings or fraudulent activities, should, nevertheless, be treated extremely seriously and the physician, group or health provider being audited should give the matter personal attention.

However, if the audit letter or audit notice is from a Zone Program Integrity Contractor (ZPIC), the matter is very serious and should not be treated as a routine audit. If the “audit” comes in the form of a subpoena, then it is extremely serious. If any FBI agent or OIG special agent is involved in it, then it is extremely serious. In any of these three cases, an experienced health attorney should be retained immediately.

Even on a “routine” audit, given the possible consequences, we recommend you immediately retain the services of an experienced health attorney to guide you through the audit process, to communicate with the auditors, and to be prepared if it is necessary to challenge the audit findings.

These are some of the actions we recommend you take and which we take in representing a physician or other health provider in responding to a Medicare audit.

All correspondence from Medicare, or the Medicare contractor, should be taken seriously. Avoid the temptation to consider the request from Medicare, or the Medicare contractor, just another medical records request. Avoid the temptation to delegate this as a routine matter to an administrative employee.

Read the audit letter carefully and provide all the information requested in the letter. In addition to medical records, auditors often ask for invoices and purchase orders for the drugs and medical supplies dispensed to patients for which Medicare reimbursed you.

Include a copy of the complete record and not just those from the dates of service requested in the audit letter.

Include any diagnostic tests and other documents from the chart that support the services provided. Many practices document the medications and immunizations given to the patient in a separate part of the chart and not in the progress notes; all documents, the complete record, should be provided to the auditor. Remember that even other physicians records obtained as history, including reports, consultations and records from other physicians or hospitals, should also be included. Consent forms, medical history questionnaires, histories, physicals, other physicians’ orders, all may be a crucial part of the record and should be included. If hospital or nursing home discharge orders or other orders referred the patient to you, obtain these to provide to the auditors.

Make sure all the medical records are legible and legibly copied. If the record is not legible, have the illegible record transcribed and include the transcription along with the hand-written or illegible records. Make sure than any such transcriptions are clearly marked as a transcription with the current date it is actually transcribed. Label it accurately. Do not allow any room for there to be any confusion that the newly transcribed part was part of the original record.

If your practice involves taking or interpreting x-rays or other diagnostic studies, include these studies. They are part of the patient’s record. If the x-rays are digital, they can be submitted on a compact disc (CD).

Never alter the medical records after a notice of an audit. However, if there are consults, orders, test reports, prescriptions, etc., that have not been filed into the chart, yet, have these filed into it, as you normally would, so that the record is complete. Altering a medical record can be the basis for a fraud claim including criminal penalties.
Make sure each page of the record is copied correctly and completely. If the copy of the record has missing information because it was cut off, the original needs to be recopied to ensure it includes all the information. Don’t submit copies that have edges cut off, have bottom margins cut off, are copied slanted on the page, or for which the reverse side is not copied. Reduce the copied image to 96% if necessary to prevent edges and margins from being cut off.

Make color copies of medical records when the original record includes different colored ink of significance. Colors other than blue and black rarely copy well and may be illegible on standard photocopiers.

Include a brief summary of the care provided to the patient with each record. The summary is not a substitute for the medical records, but will assist an auditor that may not be experienced in a particular specialty or practice area. Make sure that any such summaries are clearly marked as summaries with the current date they are actually prepared. Label it accurately. Do not allow any room for there to be any confusion that this new portion was part of the original record.

Include an explanatory note and any supporting medical literature, clinical practice guidelines, local coverage determinations (LCDs), medical/dental journal articles, or other documents to support any unusual procedures or billings, or to explain missing record entries. See item 9 immediately above.

When receiving a notice of a Medicare audit, time is of the essence. Be sure to calendar the date that the records need to be in to the auditor and have the records there by that date. Note: the due date is not the last date on which you can mail the records but rather is the date that the records must be at the auditor’s office.
Any telephone communication with the auditor should be followed up with a letter confirming the telephone conference.

Send all communications to the auditor by certified mail (or express mail), return receipt requested so you have proof of delivery.
Properly label each copy of each medical record you provide and page number everything you provide the auditors, by hand, if necessary. Medical record copies often get shuffled or portions lost or damaged during copying, storage, scanning or transmission.

Keep complete, legible copies of all correspondence and every document you provide. When we provide records to a Medicare auditor, we make a complete copy for the auditor, for the client, for us (legal counsel) and two for your future expert witnesses (to challenge any audit results) to use.

Consult an experienced health law attorney early in the audit process to assist in preparing the response.

The above check list is by no means comprehensive. Nor do we mean to suggest that you should respond on your own. The above is illustrative of the many actions that should be taken to help protect your interests when you are subjected to a Medicare audit.