Corporate Compliance?? Yeah right---

Daytonite, BSN, RN · Nov 23, 2005

I'm not sure exactly what you are referring to in reference to fraudulent uses of monies, but I suspect it has to do with a facility's choice of things it is spending it's money on. It sounds more like having to do with things like purchasing extravagant and unnecessary vacation trips for the hospital executives instead of using the money to buy supplies, new treatment equipment, make hospital improvements and pay for the costs to actually run the hospital. Money used for anything else not hospital or patient care related would be considered fraudulent use of the money.

The answers you seek are in the career of health information management. Certain doctors are permitted to charge for their time in interpreting lab and x-ray results. This is something was was worked out between Medicare, the American Medical Association, the American Hospital Association and the American Health Information Management Association long ago. These four organizations meet regularly to establish what gets paid and how it gets paid. I worked as a coder for a large group of ER docs and the amount of money an ER doc bills for interpreting an x-ray is only a few dollars. They cannot bill for reading labwork. The only docs who are paid for reading labtests are the pathologists who may bill for a professional interpretation fee. ER docs bill for an Evaluation and Management fee for each patient they see and treat. This is very similar to the fee a doctor charges you for an office visit. I don't know where you've gotten your information, but much of it is incorrect. Medicare does not pay a facility anything until after the patient has been treated. It is up to the facility to send a bill to Medicare. At the Medicare offices, the bill is reviewed. Medicare will refuse to pay for anything they feel are unnecessary charges and the facility is then left holding the bag--they cannot go after the patient for the money. This is one reason why large facilities employ utilization review nurses. Their job is to predict and advise the facility and it's doctors what Medicare is likely to pay or not pay. Many hospitals dodge these financial bullets all the time. Medicare doesn't pay hospitals as much as commercial insurance companies do and Medicaid pays even less. The payment schedules developed by Medicare are all based on piles and piles of computerized data. It has forced healthcare facilities to budget carefully or they go out of business.

The hospital and the ER doctors are permitted to bill Medicare, Medicaid and the commercial insurance companies for the services rendered to all patients they see. Those patients who come to the ER for lab tests or prior to admission are not being treated for free.

All nursing can do is treat the patients as they show up. No facility receiving any kind of federal payments may turn away any Medicare or Medicaid patient seeking care, even if they are sent there by a doctor. If the hospital loses enough money, someone at the top will, hopefully, get a financial consultant in to advise and educate the facility and the attending physicians how this all works and provide them with strategies to cut costs. It is not fair of hospital administration to place the burden of these concerns on the nursing staff because there is nothing as nurses that we can do about it other than to try not to be wasteful about using medical supplies.