Ethical Issue, need Help!

[gypsyatheart]

I have an ethical dilemma on my hands. I started working in Case Management for a small-ish hospital system (formerly a Tenet facility, bought out by 2 physicians), about 2 months ago. My specific function is Discharge Planning.

I really like the job, I like the hours, I like my co-workers. I really enjoy working in this department and, best of all, the pay for this job is outstanding! I mean really, really good. I was pretty shocked when I was told the salary, so of course, this is icing on the cake.

OK, here's the bad part.....now that I'm fully on board, been on my own the last few weeks, and am into the job, this is what is going on.

There are certain doctors, at this facility, who also own or are Medical Directors of SNF's, or that own Home Health companies, or DME companies, etc. When their patient is getting discharged, these docs are writing orders like "Discharge to "XYZ SNF", or "D/C home w/XYZ Home Health for Nursing/PT". It is so bad that these certain docs are arranging for the SNF placement w/their own facility prior to d/c, completely bypassing the CM dept. The SNF intake/admissions co-ordinators are coming onto the units, going throught the patient's charts, making copies of records, etc!

To make matters even worse...there is one doc,in particular, who is referring patients to the SNF, even when they don't need/want SNF placement, when they have family/caregivers at home who do not want SNF placement. Even after, myself, as the DCP has assessed for pt. needs and determined that SNF placement is not indicated.

I have had 2 incidents in the last week, where the doc tried to "coerce" the pt/family into SNF placement, saying the pt "had to go, they had no choice, they were being trransferred to another hospital", and trying to send them to his facility! :angryfire Also, this MD id of a certain ethnicity, his pt's are, majority, the same ethnicity, and generally non-English speaking. He basically scares these pt's into placement by telling them they "might die" if they just go home!! :angryfire

I have been able to prevent these last 2 pt's from SNF placement by telling them and their families that they do have a choice and no, they cannot be forced into this placement. This doc was not a happy camper. In fact, w/the last pt, he said "then he has to sign out AMA, I'm not going to d/c him, and no, I will not give him his d/c prescriptions, oh and you better tell him he could die from an exacerbation if he goes home!"

There is more, but that is the gist of it.....oh, did I mention he has his "reps" from his companies calling us (DCP's/CM'S), approaching us (individually) outside of the hospital and handing us bags, that when opened turn out to be expensive items like Louis Vuitton bags??!!!

I really, really like this job, like I said, and the pay is, well, it will be hard to give that up....but I feel like I need to leave here....I don't trust anyone in management, or HR, I feel like the whole culture here is corrupt....even calling their internal compliance line would be a crap-shoot...

What to do? Who can I report this to? CMS, Medicare/Medicaid?

Help!

[Mijourney]

I smell fraud. Report this to the OIG hotline and get out! I think this is physician self-referral. Check out http://www.cms.hhs.gov/ (Centers for Medicare and Medicaid). I'm pretty sure there's something in that website that can answer your question. I suggest you get out even though the money is real good. When these docs go down, you don't want to have to testify to any more than is necessary. Best wishes.

[gypsyatheart]

Exactly my thoughts, mijourney! Even though I am trying to be an advocate for my patients', it is obvious there is a lot of deceit going on here. I was also told by another staff member that one of these docs has already been under investigation....not sure what came of that however, except that "he was laying low for awhile...."

Thanks for the link!

[RN1989]

Make sure you have been writing down names and dates. You can also report these docs to the state medical board which might get the ball rolling a little faster. But they always want names, dates, specific stuff to look for to be able to take you seriously.

If you are not afraid of the consequences or can give notice ASAP so that you will be able to give your name, these agencies are much more willing to investigate. They don't like anonymous tips and although they may say you can report anonymously, the review boards can and often do dismiss anything that is reported anonymously.

I've reported on several occasions. It can be scary. Hold your ground. Good luck!

[gypsyatheart]

Thanks, RN1989 that is pretty much what I suspected.

I do plan on getting out of there ASAP...

Also, I checked out the Medicare website and read the law re: physician self-referral. Very interesting. It seems like these people could get in a whole lot of trouble for this!

"What does the physician referral law prohibit?" Answer:

The physician referral law (section 1877 of the Social Security Act) prohibits a physician from referring patients to an entity for a designated health service (DHS), if the physician or a member of his or her immediate family has a financial relationship with the entity, unless an exception applies. (The exceptions are specified in 42 CFR Part 411, Subpart J.) The law also prohibits an entity from presenting a claim to Medicare or to any person or other entity for DHS provided under a prohibited referral. No Medicare payment may be made for DHS rendered as a result of a prohibited referral, and an entity must timely refund any amounts collected for DHS performed under a prohibited referral. Civil money penalties and other remedies may also apply under some circumstances." Additional information is available at www.cms.hhs.gov/PhysicianSelfReferral/01_overview.asp#TopOfPage