Wiki Documentation of Encounter

[AliMontone]

I am practice manager for a solo practitioner and my job is now in jeopardy due to this issue. The physician states that his newly hired MA as well as his sister (not medically trained) and the new front desk employee can document the entire encounter. Cc, hpi, pmfsh, ros, occasionally the exam, as well as "figuring out the dx" from the info they gathered at intake. All of this is done without the presence of the physician in the room. He makes a brief appearance with a new patient to tell them they need surgery or an injection and the MA is left to do everything else and document or figure everything else out. They are also removing casts, sutures, and reapplying casts. He asked me if I was refusing to do this and I said yes, to do so would be fraudulent and claims would be upcoded as he is not actually documenting anything. He is spending on average 4 minutes with a patient and we see appx 40 pts a day..1 physician.. they also went over my head and added the MA in the EMR (not even a certified MA) to act as his delegate to write, sign and send rx to the pharmacies without his actual signature or review. I have flatly refused to condone this and he informed me that due to the fact that my interpretation of the rules, regulations, and laws is not how he sees it, that I will be transitioned out..am I completely and totally wrong? Or is this as unethical as it comes? His philosophy is quantity not quality and I can get on board or not...I do have my explanation to him in writing through email, with his response stating that he still needs myself and the staff to continue completing the documents including the HPI. I just need to know if I'm completely misinformed here. I am either going to quit or be fired in the next few days.

 

[Ann Kaiser]

I am practice manager for a solo practitioner and my job is now in jeopardy due to this issue. The physician states that his newly hired MA as well as his sister (not medically trained) and the new front desk employee can document the entire encounter. Cc, hpi, pmfsh, ros, occasionally the exam, as well as "figuring out the dx" from the info they gathered at intake. All of this is done without the presence of the physician in the room. He makes a brief appearance with a new patient to tell them they need surgery or an injection and the MA is left to do everything else and document or figure everything else out. They are also removing casts, sutures, and reapplying casts. He asked me if I was refusing to do this and I said yes, to do so would be fraudulent and claims would be upcoded as he is not actually documenting anything. He is spending on average 4 minutes with a patient and we see appx 40 pts a day..1 physician.. they also went over my head and added the MA in the EMR (not even a certified MA) to act as his delegate to write, sign and send rx to the pharmacies without his actual signature or review. I have flatly refused to condone this and he informed me that due to the fact that my interpretation of the rules, regulations, and laws is not how he sees it, that I will be transitioned out..am I completely and totally wrong? Or is this as unethical as it comes? His philosophy is quantity not quality and I can get on board or not...I do have my explanation to him in writing through email, with his response stating that he still needs myself and the staff to continue completing the documents including the HPI. I just need to know if I'm completely misinformed here. I am either going to quit or be fired in the next few days.

A simple answer is no you are correct, but at this point I would contact Michael D. Miscoe, JD, CPC, CASCC, CUC, CCPC, CPCO, CHCC of the AAPC Legal Advisory Board - He will be able to give you solid advice and lead you in the right direction.

 

[emcee101]

You are 100% correct. It sounds like there is widespread fraud happening. I would not want to be a part of it and would get out of there as fast as I can. I would also consider reporting this to the proper authorities because this physician's neglect for his patient could very likely be putting them at risk.