PEDIATRICS Vol. 110 No. 5 November 2002, pp. 1031
Residency Education, Billing Practices, and Compliance Issues
To the Editor.—Two articles in the October 2001 issue of Pediatrics have raised some important concerns regarding resident education today. Ng and Lawless1 provide statistics that coincide with my anecdotal experience with both pediatric and otolaryngology residents from 2 major university medical centers. That is, these young physicians receive little or no instruction in billing and compliance issues. In his commentary, Young2 correctly points out that there is more at stake than simply lost revenue when evaluation and management (E/M) coding does not correspond with a physician’s documentation in the patient’s medical record. Under the current federal law, a physician is fully responsible for each bill submitted to any payor—be it an insurance company or a state or federal agency. Under the False Claims Act, any discrepancies, upcoding, or undercoding are subject to monetary penalties that could total >$10 000 per incident. Unfortunately, lack of knowledge of proper coding is not considered an adequate defense by the federal government. Young further states that a physician is subject to criminal charges and a potential jail sentence as well. However, criminal charges are made only in those cases where specific intent can be proven.
Young also questions whether or not there is time to teach our residents about these issues. He asks, "What is our real mission: making sure that (a resident) knows why examining the skin of a febrile child is an important thing to do or making sure that her coding is correct? In my opinion, we, as educators of young physicians, have no choice in this matter. We have an absolute obligation to make certain that that resident knows both of those things—proper patient care and proper billing and coding practices. Given the seriousness of the penalties involved, the fact that these federal laws apply to all bills whether they come from a private or an academic practice and that these laws apply to even that very first bill submitted by the recently graduated resident, I feel that we would be remiss in our duties by omitting these issues in our training programs.
I could not disagree more with Dr Young when he states that "perhaps learning that incorrect coding puts them at risk is something that can wait until they are actually in the real world." The federal government has collected more than $2.9 billion since enforcing these laws in 1986.3 Furthermore, the current attorney general, John Ashcroft, has announced his intention to continue to pursue these matters with diligence.
There is no question that billing and compliance issues have changed the ways we practice medicine. It is time now to change the way we teach how to practice medicine. We have an obligation to our young doctors to prepare them for the practice of medicine in the real world. We must continue, as we have done before, to teach young doctors how to refine their patient care skills and improve their medical knowledge, but we must now also incorporate into our residency programs billing and compliance issues. Perhaps it is time to consider an even more radical change in medical education by including instruction in business and government issues in the medical school curriculum.
Jeffrey A. Koempel, MD, FAAP
University Childrens Medical Group
Division of Otolarlyngology
Childrens Hospital Los Angeles
Los Angeles, CA 90027, USA
REFERENCES
1. Ng M, Lawless ST. What if pediatric residents could bill for their outpatient services?
Pediatrics.2001; 108
:827
–834
2. Young PC. Should we be teaching residents how to bill for their outpatient services?
Pediatrics.2001; 108
:999
–1000
3. Wilson FR. Providers and counsel: essential partners. Carolina Healthcare Business.2001; July/August :10 –11
Reply.—
Thank you for the opportunity to respond to Dr Koempel’s thoughtful comments regarding my commentary. Dr Koempel points out that pediatricians need to be aware that the attorney general intends to continue to pursue them for fraudulent billing. He argues that residency or medical school is the appropriate place to teach "billing and compliance issues." My argument is not that pediatricians should be ignorant of proper billing or that they shouldn’t know how to protect themselves from being accused of cheating. I would be interested in knowing how much of that $2.9 billion came from pediatricians in general or continuity clinics in particular, but the threat that such could happen is definitely driving a new industry in the medical landscape. In my opinion, it’s a shame that someone has to have the job of "corporate compliance officer."
But that’s not the point. If, like it or not, we agree that physicians need to know about documentation and compliance, the issue becomes when to teach it. What does Dr Koempel suggest that we leave out of the curricula of medical schools or pediatric residency. What’s less important? Do we teach it to people who, at the particular stage of their learning, don’t view it as important? Dr Koempel implies that we should teach it whether the learner is ready to learn it or not. I disagree—the variations in what one needs to know about documentation vary quite a bit depending on the particular practice situation. I vote for billing and compliance to be in the curricula of continuing medical education, rather than undergraduate or graduate medical education. Certainly entities like the University Childrens Medical Group have an obligation to educate new faculty and clinicians regarding the rules and nuances of their institution’s approach to billing before they submit their "first bill."
Paul C. Young, MD
Division of General Pediatrics
Department of Pediatrics
University of Utah Health Sciences Center
Salt Lake City, UT 84132 USA
PEDIATRICS (ISSN 1098-4275). ©2002 by the American Academy of Pediatrics
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