Already Burnt out

[sarena33]

I am submitting this post as a means to get some things off my chest, as well as simultaneously get some insight and advice from other NPs in primary care.  

I am currently 18 months in to my 24 month contract at my first primary care NP job.  I graduated with my FNP degree in the fall of 2021, passed boards in the Spring of 2022, and began my current contract in June of 2022.  I have been a nurse for 13 years and prior to my current job, I worked as an RN in various ICU/PCU settings, mostly cardiology. 

The clinic is a small, privately owned practice owned by 2 MDs and one pharmacist. The pharmacist being the main owner/manager. The company consists of 3 clinics, all of which have a pharmacy attached.  I float between 2 of the 3 clinics.  In addition to seeing patients of all ages for their primary care needs, we also see patients for urgent care needs.  This happens, because the clinics are WALK-IN only. I do not have my own panel of patients. If I see a patient and request that they follow up, they don't make an appointment for that, they just come back in the requested timeframe and see whoever is working that day. This in and of itself causes a lot of issues, but it's the least of my worries. 

There are several rules, or "policies" that the pharmacist owner upholds that I do not agree with (including the walk-in model for primary care pts).  He will not take anyone's clinical knowledge, critical thinking, education, or experience into consideration when discussing these rules. 

One rule is that all patients have a urine dipstick done for every visit, does not matter why they are there.  Then, if there are any abnormalities on this UA (despite the patient's subjective complaints/symptoms, chronic conditions or lack therof), a urine PCR is sent to the lab, and this order is submitted by a medical assistant with the supervising physican's signature.  This leads to some patients getting treated for asymptomatic bacteriuria (which is very rarely indicated) by some of the other providers that I work with.  While the order does not have my name on it, the clinical note, which does have my name and signature on it, shows "urine pcr" in the plan.  

Another rule is that we are not allowed, under any circumstance, to prescribed medications for more that 90 days.  Not allowed to give any refills, doesn't matter what the medication is, what it's for, how stable the patient is, how well tolerated the medication is, or how long the patient has been on the medication. He wants them coming in for a visit with the provider every 3 months no matter what.  I will get a text from him if I give a refill past the 90 days telling me that I am not allowed to do that. This leads to many patients running out of medications, having very high BP or poorly controlled HLD and returning when they're able, usually well past the 3 month mark. I realize  that this is appropriate in certain situations, but not EVERY medication needs follow up every 3 months.

Something else that goes on is that there are 2 ultrasound techs, who work for an outside company, that hang out in the clinic throughout the day.  They will wait for patients to arrive, look at their charts and their chief complaint, pluck them from the waiting room, and perform different ultrasound tests on them without a proper provider's order or real indication.  I've had to interpret echocardiograms, abdominal US, thyroid US for patients who were told "this is what we do on all the patients." There is never a realistic indication for doing the test. They also call patients from home and tell them to come in for these tests.  This leaves the patient's scared and confused.  When I asked my bosses, why this was being done, they stated, "this helps keep food on the table for the ultrasound technicians."  In my opinion, this is insurance fraud....  

Patients also have to return to the clinic for a full visit with the provider in order to get blood test's interpreted and addressed, we are not allowed to call them and tell them anything over the phone, even if it's something harmful or dangerous such as an STD.  Granted, most of the time I do not have the resources or time to check results (don't have an inbox) or call because of the walk-in model. I see a very large volume of patients over time, and a lot of patients each day (30-35 pts per day). But sometimes I come across something concerning, I am not allowed to call and inform them of their results or the plan moving forward. 

I realize that the reasons for all of these "polices" is for business or financial reasons, but I guess this is what upsets me the most.  I was taught to be a COST-EFFECTIVE provider, which I take very seriously. Performing unnecessary tests is NOT cost-effective. The population we serve are uninsured, or on medicare/medicaid, many are non-english speaking patients with low income/education levels and limited transportation. I went into this field to help these people, but don't feel I can do this in my current position.  

I am wondering if anyone else has experienced anything similar with management.  I feel stuck, because my contract doesn't end for 6 more months, but I also feel like my license could be at risk.  When I've voiced that specific concern to my bosses, they say that they will cover the costs of any court cases or lawsuits, if it happens.  I am shocked an appalled by this answer.  My contract requires that I pay back A LOT of money if I break it prior to the 2 year mark.  I feel very burnt out and not even 2 years into this role.  I really do love what I'm doing, but feel as though I can not practice to the best of my ability in my current situation.   IF any one can relate or has any advice or insight, I would greatly appreciate it.  Also wondering if these things are standard in similar clinics.  

Thank you for reading my extremely long-winded post. 

[JKL33]

Bad situation. I do not have experience with this but I do know that I would refuse to participate in any part of their fraudulent schemes (which I agree some of this seems to meet that definition and honestly needs to be reported) and let the chips fall where they may. Let the guy text you about his rules, who cares. They may have a hard time enforcing a contract where the terms involve unethical medical practices and defrauding the government. Talk to a lawyer about your contract and how best to separate from them given their illegal activities.

Good luck ~

[Nurse Beth, MSN]

Have you thought about reporting these practices to Medicare?

The Medicare number to report fraud is 1-800-822-6222. You can also do this through an attorney. There are rewards for whistleblowers.

[sarena33]

JKL33 said:

Bad situation. I do not have experience with this but I do know that I would refuse to participate in any part of their fraudulent schemes (which I agree some of this seems to meet that definition and honestly needs to be reported) and let the chips fall where they may. Let the guy text you about his rules, who cares. They may have a hard time enforcing a contract where the terms involve unethical medical practices and defrauding the government. Talk to a lawyer about your contract and how best to separate from them given their illegal activities.

Good luck ~

Thank you for your response.  I have definitely thought about attempting to get out of the contract.  My concerns are that I'll burn bridges and not have their support in future job applications.  Right now, I know the two physicians would write a good letter of recommendation to future employers. But, if I hired a lawyer and attempted to get out of the contract early, especially with claims of fraud, I'm not sure they would.  ?  Also, most job postings that I'm seeing require 2 or 3 years of experience, so I feel like it would benefit me to just put my head down and finish the contract.  I don't want to "settle" again when it comes to finding a job. 

[sarena33]

Nurse Beth said:

Have you thought about reporting these practices to Medicare?

The Medicare number to report fraud is 1-800-822-6222. You can also do this through an attorney. There are rewards for whistleblowers.

Thank you for your response.  The thought has crossed my mind on multiple occasions.  Is there any benefit to reporting sooner rather than later? I don't want to burn any bridges and not have the option of asking them for a letter of recommendation when I apply for new jobs.  If I call this number several months after leaving that job, can I still report the fraud? Any idea what type of "proof" or documentation I will need, if any? Thanks again.

[Nurse Beth, MSN]

 

sarena33 said:

Thank you for your response.  The thought has crossed my mind on multiple occasions.  Is there any benefit to reporting sooner rather than later? I don't want to burn any bridges and not have the option of asking them for a letter of recommendation when I apply for new jobs.  If I call this number several months after leaving that job, can I still report the fraud? Any idea what type of "proof" or documentation I will need, if any? Thanks again.

I don't think you need to provide proof because they will conduct their own investigation and review what has been submitted to Medicare for reimbursement.

I agree that waiting until you have completed your contract may be better for you. It's only six months. Best wishes.

[offlabel]

Nurse Beth said:

 

I don't think you need to provide proof because they will conduct their own investigation and review what has been submitted to Medicare for reimbursement.

I agree that waiting until you have completed your contract may be better for you. It's only six months. Best wishes.

What happens when the investigators implicate the op in fraud as well and the practice throws him/her under the bus for whatever participation he/she has already had? And allege he/she only blew the whistle motivated by spite/poor work eval, whatever? Kicking a turd on a hot Summer day means you get manure on your boots. Be very careful of the advice you give....

[Nurse Beth, MSN]

offlabel said:

What happens when the investigators implicate the op in fraud as well and the practice throws him/her under the bus for whatever participation he/she has already had? And allege he/she only blew the whistle motivated by spite/poor work eval, whatever? Kicking a turd on a hot Summer day means you get manure on your boots. Be very careful of the advice you give....

I'm not an attorney, but here are some general considerations about whistleblower risk:

• Whistleblower protection laws are in place to safeguard individuals who report illegal or unethical activities from retaliation. 
• Thoroughly document any evidence or information related to the reported issues. This documentation can serve as crucial evidence in demonstrating the legitimacy of the whistleblower's concerns.
• If an individual is implicated and faces potential legal consequences, seeking legal representation from a lawyer with expertise in whistleblower protection is essential. 
• Whistleblowers should ensure that their motivation is based on a genuine concern for wrongdoing and ethical behavior rather than personal grievances. 
• If the whistleblower faces retaliation, they may have grounds for a retaliation claim. 
• Consult an attorney for answers to the concerns you raised. Seeking legal advice early in the process can help individuals make informed decisions about reporting concerns related to fraud or unethical behavior.

[djmatte, ADN, MSN, RN, NP]

I will say there are a few things here that are concerning regarding potential for fraud. Especially with things like unnecessary testing and procedures like ultrasounds or unsupported treatment of bacteria (likely through the attached pharmacy). But having a "walk in only" clinic isn't specifically one. A clinic can set the parameters of patient follow up and whether they schedule out or not. When I worked in an underserved area. I saw many clinicians bring their patients with chronic diseases in quarterly because it often decreased use of v the ED because ancillary concerns/complaints could be more easily addressed. It certainly padded the clinic schedule, but reduction in emergency use is a HEDIS measure as well. 

there are certainly red flags here that could warrant a Medicare investigation. Just make sure your own decisions meet a level scrutiny as well. Your name is on some of those charts. 

[sarena33]

djmatte said:

I will say there are a few things here that are concerning regarding potential for fraud. Especially with things like unnecessary testing and procedures like ultrasounds or unsupported treatment of bacteria (likely through the attached pharmacy). But having a "walk in only" clinic isn't specifically one. A clinic can set the parameters of patient follow up and whether they schedule out or not. When I worked in an underserved area. I saw many clinicians bring their patients with chronic diseases in quarterly because it often decreased use of v the ED because ancillary concerns/complaints could be more easily addressed. It certainly padded the clinic schedule, but reduction in emergency use is a HEDIS measure as well. 

there are certainly red flags here that could warrant a Medicare investigation. Just make sure your own decisions meet a level scrutiny as well. Your name is on some of those charts. 

I agree that "walk in only" is not unethical or considered fraudulent. It's frustrating and decreases continuity of care, thus poor quality of care. Bringing someone in quarterly to reduce ED visits makes sense for a lot of patients depending on their age, co-morbidities, medical hx, and medications.  But I have 25 year old patients who are required to come in every three months for their topical acne medication that they've been on for years, absolutely ridiculous. I've also seen 20 year old women get pregnant because they weren't able to get back to the clinic every 3 months for their birth control. Withholding someone's contraceptive is unethical, especially if they're taking a method that is completely medically appropriate and safe for them to take. The birth control issue was one that I fought and won, now the clinic allows 1 year refills for BC because of me, but that was not the case for many years before me.  I am about 99% sure that that the owner (who is not a physician or a provider) does not require the quarterly follow up to reduce ED visits, but instead to create higher volume of patient visits on a daily basis for more money.  

My name is not on any charts that are tied to the unnecessary ultrasound ORDERS, it's my supervising physician that does all of that. However, the patients do come to me asking why the test was done and I tell them the honest truth. I also document in my note. "patient asks about abdominal US that was completed on xx/xx/xx.  Unsure why test was completed and do not see a medical indication documented in the patient's chart...etc." I suppose I should talk to a lawyer about the best way to maneuver that documentation. Due to personal circumstances I probably will not report anything until after my contract here is over and I've secured a new job. In the meantime, I should talk to a lawyer about what to do until then.   

Thank you for your thoughts. 

[NRSKarenRN, BSN, RN]

Medicare/Medicaid Fraud and Abuse: Prevent, Detect, Report  education is must read for all providers.  Ultrasound issue you describe falls under "Knowingly ordering medically unnecessary items or services for patients".   

Your phrasing ""patient asks about abdominal US that was completed on xx/xx/xx.  Unsure why test was completed and do not see a medical indication documented in the patient's chart...etc." sounds like prudent documentation to CYA.   Any staff meetings when this concern discussed; emails sent, etc -- keep copy for your records as paper trail. 

Thanks for being concerned--  see page 20 above article  --providers can contact

OIG Hotline:
Phone: 1-800-HHS-TIPS (1-800-447-8477) or TTY 1-800-377-4950
Fax: [phone]
Online: Forms.oig.hhs.gov/hotlineoperations/index.asp

Mail: U.S. Department of Health & Human Services
Office of Inspector General
ATTN: OIG Hotline Operations
P.O. Box 23489
Washington, DC 20026
OR
● Contact your MAC

[traumaRUs, MSN, APRN]

I'd contact a lawyer about getting out of that contract. Reeks of fraud with unnecessary and BILLED tests.  Yike!