One of the most important issues this year for emergency medicine physicians — audits — seems to be slipping by without a lot of notice. How is cost containment going to impact emergency physicians?  Well, it could put us “up on a RAC,” for starters.

Recovery Audit Contractor (RAC) programs that examine physician documentation for signs that an admission was not justified have “corrected” $1.03 billion in “improper payments” by Medicare in Florida, California and New York. In other words, if you (the physician) have not documented how sick the patient is and how long you intend to treat them, your hospital could be denied the admission, have to pay fines and a third-party auditor could be reimbursed a percentage for finding the problem.

An obvious target here is the weak chest pain admission who is a full admission, but is tested and discharged from the hospital in 18 hours. Care managers on the floor will no doubt try very hard to scrape together enough documentation to keep the hospital paid, but they will be looking to your documentation to do it — and no one else but you can document the projected length of treatment, since you were the only one thinking about it at the time!

For example, I had a patient last week with a chief complaint of “ear pain” in a fast track tell me that, incidentally, she had been having a few episodes of chest pressure, but if she sat down, it went away. She didn’t much like to take her blood pressure meds or her diabetes meds, but since this started a few days ago she had been taking them faithfully. I could have handled my “ear pain” patient one of four ways:

  1. Avoid the hassle of documentation, release the patient and hope she’s not really at risk for heart disease (I’ve got a great attorney);
  2. “Put them in OBS(ervation),” which I don’t really think is appropriate and it coughs up about $4,000 for the hospital, but I’m probably going to survive an audit;
  3. Document a few details and put the patient in inpatient care; hope that the hospital isn’t audited (putting the hospital is at risk for about $6,000 they may have to pay back after an audit); or
  4. Thoroughly and accurately document the patient’s medical decision making and intensity of service, so that she’s qualified for inpatient care. It may take a minute, but I’m just fully documenting the truth of the situation.

The cynic in me is thinking that the payor side would like to see a lot of #2. There is nothing the hospital CFO wants to see less, of course. However, this is an opportunity for us in emergency medicine to once again demonstrate our alignment with the hospital, as well as our understanding of the financial issues that surround the ED, and push to make #4 the standard. If you want to be immediate friends with a hospital CFO right now, your willingness to address this issue will be a big help — and those of us that have an independent group contracted with the hospital know that we need all the help we can get there.

RAC applies to all of us that are responsible for hospital admissions. Let’s let the cardiologists take the heat here, get our story and documentation straight and take credit in the executive office. We have an opportunity to shine here, which comes not often. Let’s take advantage.

P.S. For those wondering, my very nice “ear pain” lady had her stents put in; she had a real disease. And, I just recently read the cardiologist’s note. It’s about six lines long.

– Dr. Mark Crockett