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I am 87 years old, with a problem of the prostate gland. Before I met Dr. Baum, I went to the bathroom every 30-60 minutes. After Dr. Baum's treatment on my prostate, I go only 5 times per day and only 1 time at night! You turned my life around. I am so very grateful!

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When Big Brother Looks at Your Practice
Under the Microscope

Few of us would have believed that George Orwell's 1984 big brother would have arrived on the health care scene and looked not only over the shoulder but into the records and books of the American physician. But that reality is here and most of us will experience someone from the government, managed care plans, or third party payors will be making an uninvited visit to many practices in the very near future. This article will review what you are obligated to share with these snoopers and what are the legal implications that protect you in the event that you are asked to reveal your records.

You can expect that with concerns about quality and cost control accompanied by the increasing or perceived surplus of physicians, that third parties will be looking at the office practice of physicians in greater detail and frequency. In the future standards and guidelines are being established beyond the actual clinical practice of medicine to the office management of records and reporting.

In the past the third party payors were only concerned with the claim form submitted by the physicians. This rustled in a check for the billed services. Now the payors have a responsibility to look beyond the claim form in order to be accountable to the consumer, the employer or the stockholder, who are paying the health care bill. The payor is now motivated to assure financial success which they believe can be accomplished by entering our offices to evaluate the function, efficiency, and most important the cost-effectiveness of our practices

The government also has a responsibility to assure compliance with regulations and to eliminate or prosecute instances of fraud, abuse, waste and inefficiency.

Who will be knocking on our doors?
Organizations that are responsible for quality and standards, payors, and those that are concerned with fraud and abuse will be the most common visitors to our practices. This includes local law enforcement bureaus, health, police, and fire departments as well as insurance companies, managed care plans, employers, Medicare, FBI, Secret Service, CLIA, HCFA OSHA, state medical boards and many other law enforcement agencies.

How can we prepare for the investigations?
You can prepare by practicing high quality medicine in an ethical fashion accompanied by careful, meticulous documentation. You can begin by having a plan for any request for information. This plan must be known to everyone in the office, especially those individuals at the front desk who are the first ones to meet those investigators entering our practices and the ones that are most likely to receive request for information. The physicians and the staff should have a plan of action, which translates, to who is in charge of information and records and what information may or may not be released.

Rule number one is that no information should be given over the telephone. When a request arrives, by mail or in person, the responsible individual in the office should be notified. Someone requesting information should identify himherself and state what is desire and what is the purpose of the request. If the person is a representative of an agency, it is worthwhile to call that agency to confirm the validity of the credentials and the type of information requested. If immediate access is required, such as the fire or health department, that information should be released for the reason specified.

If there is a request for patient information, the necessary signed and witnessed permission releases should be received from he patient prior to divulging the confidential information. Always error on the side of maintaining patient confidentiality before releasing any information. For example, if a managed care plan request to examine your charting techniques, remove the patient's name first to preserve the patient's confidentiality.

In addition to receiving a written release from the patient, we advise not to provide any additional information beyond what is specifically requested. If specific documents such as medical records are requested, do not release them without a witness such as your office manager being present. We also suggest that the designated person in your office that communicates with the investigator, record what information is released and never provide the original documents.

If a criminal investigation occurs, you need to see a legal warrant and you will need to contact your attorney before releasing any information. Your attorney should be present during interviews and the staff should be notified of the investigation.

Make every effort to avoid the impression that you are withholding information. Of course, never alter or falsify any documents.

We advise that this plan of action should be clearly written in the policy manual and approved by the office legal counsel. This information should be disseminated to all the personnel in the office.

What are our rights and what do we need to show the investigator?
It depends on who is requesting the information what information is requested. Your local health and fire departments may walk into your office at any time without notice to determine if any violations occur. These inspectors are, however, limited to their specific areas of responsibility. The fire department is expected to confine their investigation to fire safety. The same applies to the health department with no involvement in patient's records or confidential information.

On the other hand, an investigation of fraud, where the Office of the Inspector General, the Justice Department or the FBI is involved, will require a warrant for their visit. The warrant will stipulate what is requested. They may request to review patient records financial records or for that matter, almost anything else they wish to review.

How can we minimize our exposure?
The best advice is to play by the rules. Have a policy manual with office policy and OSHA policies in effect. Be proactive, and have a plan of action in place before the investigators knock on your door with their microscope. It is important to understand that most inquiries should not be threatening and have a purpose of helping the patient or the payor get the best value and quality.

How does this apply to managed care plans?
Managed care plans, insurance companies and even Medicare have contracts with employers, consumers and providers. In most instances, the physician signs a release to make patient information available to managed care plans or insurance companies upon request. Therefore, we need to comply with those request if we sign such an agreement.

Managed care plans success depends on their fiscal responsibility. Not only are managed care plans evaluating offices on outcomes, length of stay, and costs, but they are also looking at patient satisfaction, friendliness of the staff and over-all patient satisfaction or happiness with the service that they receive. This information can only be determined when investigators look at our practices from all the angles. They will be visiting our offices more frequently, seeking information through mail and in-person surveys

We need to take proactive steps for conducting an efficient, cost-effective, quality practice. We need to set high standards and to evaluate our practices to see if we are meeting or better yet, exceeding those standards. The bottom line is that we need to consider the patient first and do everything necessary to provide effective, cost-efficient care in a user-friendly fashion. If we do that we need not fear the investigator's microscope.