What would you do? Fraud and hospital privileges

June 6, 2003

Faced with a respected doctor accused of Medicaid fraud, his hospital staff had to decide whether to suspend him. We'd like your vote, too.

 

WHAT WOULD YOU DO?

Fraud and hospital privileges

Faced with a respected doctor accused of Medicaid fraud, his hospital staff had to decide whether to suspend him. We'd like your vote, too.

By Renate G. Justin, MD
Family Practitioner/Fort Collins, CO

 

When I met Jim Brown in the hospital parking lot that morning before early rounds, it was clear that something was wrong. He didn't return my greeting, and he took the stairs instead of joining me in the elevator. I thought perhaps he was worried about a patient, or that he'd had a fight with his wife. (Although this incident took place years ago, I've changed Jim's name to protect his identity.)

What would you do?

If you were on the hospital staff deciding Dr. Brown's fate, would you:

1. Revoke his privileges immediately?
2. Do nothing, and let the courts and the state medical board deal with the problem?
3. Suspend him temporarily until the state board decides whether to take action.

Cast your vote in our WEB POLL(voting deadline 6/19/03).

We'll report on your response to our Web poll in an upcoming issue, and tell you what the medical staff actually decided.

When I got to my office, and my secretary showed me the morning newspaper, I understood Jim's odd behavior. A front-page story reported that he'd been accused of Medicaid fraud, allegedly charging for office visits with patients he hadn't actually seen. I was shocked.

The president of the medical staff called an emergency meeting for 5:30 that afternoon, the first such session I'd ever attended. We didn't gather in the staff meeting room as usual, but in a soundproof, windowless, basement classroom. The atmosphere was somber, and filled with apprehension. It mirrored the way I felt.

After everyone was seated, Jim Brown entered the room. Tall and good-looking, he was a board-certified ob/gyn who'd been our respected colleague for several years. He had been asked to appear without his lawyer, to explain to us what had happened. With all of us seated, he remained standing, as though he'd already ceased to be part of our group. There was utter silence.

"I think everyone here knows why we called this meeting," the staff president said. "Dr. Brown, we'd first like to ascertain if what you're accused of is really true."

Jim answered in a clear voice, "Yes, I did charge for two visits for each Medicaid office visit so that I would break even." That was all he said.

The president asked, "Do you realize that we have called this meeting to decide whether you can maintain your hospital privileges?"

"Yes," Jim replied.

"Do you have any questions before we decide?"

"No."

"In that case, you may be excused."

As Jim left the room, we shifted in our chairs, uneasy about the task ahead of us. One of our most competent, well-liked colleagues faced professional catastrophe, as well as the prospect of jail. I knew his wife and four young children well, and I couldn't imagine what would happen to them if he had to stop practicing medicine.

I admired Jim for accepting Medicaid patients, but I was also angry with him for compromising his reputation and endangering his family. As a member of the medical staff, I felt sad that I had the power to ruin Jim's family by denying his hospital privileges. The responsibility of judging him weighed heavily on my shoulders, and I wished that being a member of the medical profession didn't include that requirement.

As the meeting got underway, it became clear that there was a wide difference of opinion among our group. Some, including the pious dermatologist who always refused my Medicaid referrals, insisted that physicians must always be truthful, and that lying and cheating simply couldn't be tolerated in any staff member.

Others thought Jim's actions were justified. After all, they argued, if he saw numerous Medicaid patients, he had to cover his overhead. His scheme didn't do any more than that, and he certainly wasn't going to get rich from it. Some of us, including me, felt guilty because we saw few Medicaid patients, whereas Jim accepted them all.

A sizable group felt that staff privileges should be based only on medical competence, not moral behavior. An older obstetrician pointed out that Jim's medical expertise was beyond criticism. In fact, that's why he'd been elected head of the hospital's ob/gyn department. Another doctor argued that illegal acts were not medical staff business, and should be left to the judicial system.

One doctor objected: "If a physician shows gross medical incompetence, and thereby does harm, he can end up in court for his negligence. The judicial and legal systems complement each other, but do not exclude each other." This speaker read the following passage from the AMA Principles of Medical Ethics: "A physician shall . . . strive to report physicians . . . engaging in fraud or deception."

Someone interrupted: "It's not a question of our exposing Dr. Brown. He has already been exposed."

The first speaker continued reading: "A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient." Another doctor commented: "Sure, just try to change the Medicaid payment rates!"

The debate dragged on well past dinnertime. Finally someone suggested a compromise: Suspend Brown from the hospital staff until the state's Board of Medical Examiners could decide whether to restrict or suspend his license. This proposal had the advantage of shifting responsibility, thereby freeing us from having to make a decision. The idea appealed to many, although several physicians feared that our emergency room and on-call staff would be flooded with Jim's ob Medicaid patients.

 

What would you do?

If you were on the hospital staff deciding Dr. Brown's fate, would you:

1. Revoke his privileges immediately?
2. Do nothing, and let the courts and the state medical board deal with the problem?
3. Suspend him temporarily until the state board decides whether to take action.

Cast your vote in our WEB POLL.

We'll report on your response to our Web poll in an upcoming issue, and tell you what the medical staff actually decided.

 

Renate Justin. What would you do? Medical Economics Jun. 6, 2003;80:50.