Medical discretion or Medicare fraud?

In recent decades, hospital stays have generally gotten shorter. Many procedures that would have traditionally required at least a few days of recovery in the hospital are now done on an outpatient basis. This is partially due to innovative techniques, which allow procedures to be less invasive, therefore allowing for a quicker discharge. It may also be a result of increasing pressure on doctors and hospitals to reduce the costs associated with overnight hospital stays.

One of the nation’s leading hospitals is currently under federal scrutiny concerning whether doctors’ decisions to admit a patient were the appropriate exercise of medical discretion or constituted Medicare fraud. This is not the first time that federal regulators have investigated hospitals for this reason. In 2008, St. Joseph’s Health System in Atlanta paid millions of dollars to settle allegations that one-day hospital stays had resulted in improper billing to Medicare.

In the ongoing case, federal investigators have subpoenaed six years of medical records from Beth Israel Hospital. The investigators are searching for instances where a patient was unnecessarily admitted. But while the scrutiny of hospital admissions is increasing, Medicare does not provide clear guidance on when a patient should be admitted and when they may require only a few hours of additional observation.

The concern among many is that a doctor has a US Attorney virtually looking over her shoulder and questioning the doctor’s decision to admit a patient to the hospital. If federal investigators feel like the hospital is attempting to defraud the Medicare system, hospitals can face criminal charges.

Source: The Boston Globe, “Hospital’s Medicare billing examined,” Liz Kowalczyk, Feb. 4, 2012