Medicine Means You Never Have to Say You’re Sorry

Just as hospitals are encouraging us to apologize for our mistakes, comes a warning from Steven I. Kern, JD.  He cautions that admitting errors may result in loss of malpractice coverage.  He states :

For example, many malpractice insurance policies include a clause that allows the carrier to deny coverage if you do anything that adversely affects its ability to provide a defense.

He relates that saying sorry is basically an admission of wrong doing, and that anyone who hears you say that you are sorry can be used as a witness to testify against you in a malpractice suit.  Mr. Kern also notes that the push by hospitals for physicians to admit to mistakes may actually be based on an effort by the hospital to shift liability away from the hospital and toward the physician.  Yikes!  He also notes that saying sorry can lead to sanctions from peers, family wrath and economic loss.   What he recommends is that first, notify your “health care” attorney, and then together decide if you should notify your insurance carrier.  He then states that the three of you decide if it is appropriate to say “sorry.”  After that, the three of you will craft an appropriate response “to best communicate your regret in a way that is likely to make matters better, not worse.”

Mr. Kerns advice is good, but sad.  How pathetic that we live in a society where admitting we are human and that we have made a mistake is fraught with danger.   He does note that 35 states have variations on ‘apology laws’,  which he describes as “exempting expressions of sympathy and empathy to exempting admissions of fault.”  However, I still would check with your malpractice carrier first before making a move.

As he notes:

Unlike in church, confession doesn’t necessarily lead to absolution in the world of medicine.

I don’t know about you, but last time I checked, I was only human.  Crazy place, this world.

Billing for Phone Calls: Acceptable Practice or Reptilian Behavior?

My trusty health insurance, for which I pay handsomely, (yes, I am self-insured) sent me an email titled, “Calls could cost you.” It states that calling your physician may cost you. I quote:

“Many times people call their doctor to ask a question, resolve a concern, or ask about a referral. Traditionally, doctors haven’t charged to answering these questions. In certain cases, that’s changed.

New rules have been established that allow doctors to charge for telephone consultations in some circumstances. To be a billable call, the patient must not have been seen by the doctor for a week before the call or within 24 hours after the call. If the doctor provides services that could have happened at a regular office visit, then the doctor can submit a claim. The doctor must let the patient know the call isn’t free and that he or she intends to bill.

If the doctor does submit a claim to Humana, we’ll treat it as if the doctor filed a claim for an office visit. So if your benefits have co-payments for an office visit, you’d owe the doctor your co-payment for an office visit. If your Humana plan has a deductible, we’ll apply the allowable claims costs to your deductible. You’ll pay the allowed charges, unless you’ve met your deductible.

These rules don’t apply to most calls people make to their doctor. But Humana wants you to know that under current national rules, doctors can bill both Humana and their patients for some telephone visits.

It’s important to know that calling your doctor could cost you in some circumstances. If you’re aware of the rules, you could save yourself some money.”

Hmmm, this is interesting. What patients should you manage over the phone? What are the legal ramifications? Ethically, what is involved in charging for phone calls?  God forbid, are we behaving like lawyers? I don’t know about you, but I always prefer to see a patient rather than prescribe over the phone. I know some patients absolutely refuse to come in, “I don’t have time,” but I am loathe to diagnose and prescribe over the phone.    (And these are the patients I think are most likely to sue-they seem to be looking for a way to work around the system.)

My take-
If a patient is ill they need to be seen.
If you are going to bill for phone calls, and it is certainly justified in some cases, be impeccable in your documentation.
Establish criteria ahead of time of what sorts of phone calls you will bill for, and what cases ABSOLUTELY must be seen in the office.
Teach your staff how to triage calls.

Following are the codes for phone calls.  (From From the January ACP Internist, copyright © 2008 by the American College of Physicians.)  If anyone is doing this, I would love to hear back as to which insurers are reimbursing, and how you determine which patients are appropriate to be managed by phone–e.g.  coumadin management? 

99441: Telephone E/M service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; five to 10 minutes of medical discussion
99442: 11-20 minutes of medical discussion
99443: 21-30 minutes of medical discussion

As to liability, here are some guidelines from CRICO/RMF, the medical malpractice company for the Harvard Medical Community.  (http://www.rmf.harvard.edu/patient-safety-strategies/communication-teamwork/telephone-technology/faqs.aspx#Q31)

“Documentation of all phone calls in which medical information is discussed is extremely important. The date and time of the call, patient’s complaints, and advice given should all be recorded. The advice given should include the point at which the patient should seek medical attention. The few minutes taken to record this information will be valuable for ongoing patient care. In the event a patient challenges the quality of medical care they received by phone, or claims he or she made multiple calls and received no or inadequate advice, such documentation will prove worthwhile.”

Good luck with this!  I think that coding for phone calls has a lot of potential for good and bad, and would tread lightly.  And just to make you smile, I got an automated phone call from Humana while I was writing this, encouraging me to visit their web site, where I could get medical advice “tailored for me.”  Shoot, who needs an MD?  Just throw up a web site with generic advice and call it a day!