Dear Patient: I didn't commit Medicare fraud. Here's why...

Dear Patient: I didn't commit Medicare fraud. Here's why...

Questioned about the validity of her charges, the authorcomposed a letter that left little doubt that she was underpaid.

I recently received this letter from a patient I had successfully treatedfor pneumonia:

Dear Dr. Rahn:

I am writing to complain about the bills you sent to Medicare after myrecent hospitalization. You came in every day to examine me and to discusstest results and plans. But your visits were short and hurried. Your chargesfor those days are clearly excessive.

I am doing well now and have no quarrel with the care I received. ButMedicare is asking us to report possible fraud and abuse by physicians.Before I do that, I would like an explanation of your charges.

Sincerely,

Your Patient

Once I'd overcome my anger, I decided to use the occasion as a "teachingmoment." Proper communication between doctor and patient, which isalways critical, has taken on even greater importance now that Medicarehas anointed our patients as watchdogs. We simply have to let them knowmore about what we do for them--and why. In that spirit, I prepared thefollowing response for my skeptical patient.

Dear Patient:

I am glad you're making a good recovery after your recent hospitalizationfor pneumonia. Although I regret that time pressures made it impossiblefor me to visit with you as long I would have liked, there were other aspectsof your care--not clearly evident to you--that I devoted time and attentionto every day. This work began immediately after I examined you in my officeand determined that you had right middle lobe pneumonia. It continues tothis day.

1. Although current clinical guidelines recommended that I treat youas an outpatient, experience told me you were too sick to combat your illnessat home. I arranged for your hospitalization.

2. I designed your care plan, ordered the correct laboratory tests, chosethe proper antibiotics, and wrote orders to the nurses, pharmacy, and respiratorycare team.

3. I reviewed your tests daily, considering whether there were othertests I should order to track down possible abnormalities and correct problems.At one point, for example, your blood sugar was quite high. To make surethat test was an aberration and you weren't a diabetic, I arranged retesting,which showed your blood sugar had returned to normal.

4. When your tests weren't available for review on schedule, I phonedthe lab and radiology department to get the results.

5. I visited the library to do a literature search of your monoclonalgammopathy to see how this related to your pneumonia. I was pleased to findmy concern about your immune system was unwarranted.

6. I visited the radiology department to discuss with the radiologistwhether your X-ray suggested we needed a CT scan of your chest. We decidedto schedule the scan.

7. After I discussed the CT with you, I bargained with the ordering clerkto get you in before the typical three-day wait. I again conferred withthe radiologist about the test results.

8. I tracked down the pulmonologist for a consult and conferred withhim about his findings.

9. I called in a cardiologist to clear you for the bronchoscopy, andcoordinated the timing of your tests.

10. I answered a note from the hospital pharmacy committee suggestingthat I switch you to oral antibiotics to save the hospital money. SinceI felt you would benefit from one more day of IV antibiotics, I persuadedthe committee that was necessary.

11. When respiratory therapy department staff suggested you had exceededthe oxygen usage outlined in the protocol, I convinced them to continuethe oxygen, because you were still short of breath.

12. I took three or four phone calls each day from nurses informing meof your vital signs or of test results.

13. I took a middle-of-the-night call seeking authorization for the sleepingpill you requested because the hospital hallway was noisy.

14. When I suggested you could go home, but you objected because youhad no one to care for you, I convinced the utilization review nurse thatyour hospital stay should be considered a medical necessity.

15. I met with the social worker to arrange for home health care, meals-on-wheels,and respiratory therapy.

16. I made several calls to your family in Wyoming regarding your progressand follow-up care.

17. I am now wading through a barrage of paperwork resulting from yourhospital admission and discharge, and your home health care.

I willingly spent time on these matters because I felt they constitutedgood care and were essential to your comfort and recovery. I extend myselfsimilarly to all my patients--in ways that never appear on bills and arenot compensated by Medicare.

I look forward to your returning to my office for follow-up so that wemay both ensure your ongoing good health. Please continue to contact mewhenever you have questions.

Sincerely,

Ada C. Rahn, MD

By Ada C. Rahn, MD, Internist/ Elmhurst, IL

Ada Rahn. Dear Patient: I didn't commit Medicare fraud. Here's why....

Medical Economics

1999;16:135.