Your liability for expressing "informal" medical opinions about hospitalized patients

Q. As hospitalists get more involved in care it's become common for primary care doctors to pay informal visits to their patients in the hospital. Could primary care doctors be held liable for expressing an informal opinion on the treatment course, although they have not documented any discussions in the medical record or billed for the visit? Is it better to document and try to charge, although there is often nothing legitimate to bill for?

A. Virtually every payer requires that services billed for be medically necessary. Just checking on a patient usually doesn't meet that standard. If the doctor hasn't written anything in the chart, there is no documentation upon which to bill, but likely there is no record of informal information either. If the doctor isn't attending the patient in the hospital, the likelihood of liability regarding hospital-based services is not high. Trying to document something unnecessary, including an "informal" and unrequested opinion, would be more likely to increase liability.

Alice G. Gosfield, JD
Alice G. Gosfield and Associates
Philadelphia, PA
agosfield@gosfield.com