They’re Watching Us: Profiling Serial Billers
Aug 5, 2015
by Dr. Jon Elion

Getting physicians to care about Clinical Documentation Improvement in the acute care setting can be challenging, as they may feel that it benefits only the hospital, not them. After all, better documentation often leads to higher reimbursement to the hospital, but does not directly affect physician reimbursement.

One harsh reality that physicians need to learn and accept is that insurance companies (and even hospitals) are tracking and profiling practice and clinical care patterns. This is best explained with an example. Let’s look at a situation where a patient is diagnosed with acute cholecystitis and then undergoes a laparoscopic cholecystectomy. On the first post-operative day, the surgeon writes this note: “The patient is complaining of abdominal pain. On examination, blood pressure is 90/60, pulse 113, respirations 22, temperature 39°C. There is abdominal tenderness with rebound tenderness.  White blood cell count has risen to 12.6 thousand. Will check an x-ray of the abdomen and an abdominal CT scan, request an Infectious Disease consult and start intravenous ciprofloxacin.” The patient improves, and is discharged on post-op day 6 on oral ciprofloxacin.

While any physician reading that note would be able to discern the surgeon’s thinking, the hospital coders are not permitted to use their clairvoyance, and will only be able to code for the Acute Cholecystitis with a Laparoscopic Cholecystectomy. This would be associated with an expected length of stay of 2.4 days, and a typical reimbursement of $8,168 (this amount is listed solely for illustration, and will of course vary depending on the Medicare rates at any given hospital). Based on this information, an insurance company may conclude that the surgeon kept the patient in the hospital longer than expected, and that the considerable additional resources used (the CT scan, Infectious Disease Consult and IV ciprofloxacin) were not justified for an uncomplicated laparoscopic cholecystectomy. The surgeon is now at risk to be classified as inefficient and costly in his care.

If his note had simply added phrases such as “probably acute peritonitis” and “probable sepsis” (which is what his note actually described), the expected length of stay would go up to 6.2 days and the reimbursement would rise to $17,477. With that documentation in place, the length of stay is appropriate and the additional resources expended would be considered appropriate.

So what might an insurance company do if they felt that a physician was an inefficient “over-utilizer”? In October 2013, the Providence Journal ran a lead story with the headline “United Healthcare Dropping R.I. Doctors From Medicare Advantage Network.” Similar headlines appeared in many states around the same time. United Healthcare never said why they took this action (nor were they required to), but it would not be a leap of logic to expect a health insurance company to want to drop inefficient physicians from its plans.

As if this is not enough motivation, more and more hospital and physician statistics are showing up in local newspapers. Hopefully the newspapers take the time to use risk-adjusted morbidity and mortality rates (rather than raw numbers). This means that it is important for physicians to fully document co-morbid conditions in their patients so that the statistics are accurately adjusted for risk, and the quality of care provided by each physician is properly represented.

Physicians are being watched. They are being profiled. They must care about Clinical Documentation Improvement!

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