Ethical question responses
Bonni Wilke
Description
Collection
Title:
Ethical question responses
Creator:
Bonni Wilke
Date:
3/22/2019
Text:
First off, thank you to everyone who took the time to respond. This patient does not have health insurance and he is trying to get vocational rehab to pay for his prosthesis. There is no insurance to complain to. Vocational rehab told the patient that they would require that the RX come from the surgeon who amputated. That is when I submitted my inquiry to the list serv. Vocational rehab has since said to the patient that the RX does NOT have to come from the surgeon. I received that news yesterday (03/21) afternoon. In any normal circumstance we would always have the patient get an RX from another physician. I appreciate the suggestions of trying to bypass the surgeon altogether, however, that was not an option according to what vocational rehab said they would require. As for facilitating a relationship with this surgeon, that will not happen. We have been in business for several decades and this particular surgeon has an established relationship with one of our competitors and absolutely WILL NOT deviate. It's very much a good 'ol boys situation/club. We're just going to keep on rocking and rolling without his referrals and continue to do what's best for the patient! Always. Thanks again everyone! Responses are below for all who were interested in them.
1. Send the patient to his PCP to get an Rx and documentation and bypass the surgeon all together.
2. Is there an insurance complaint line?
3. Find different doctor to sign Rx and document- done.
4. Take your patient to a physiatrist. They are best ever resource for good notes and Rx. You always should have physiatry available for referral. Gods, even a family doc will write it. Some get kick out of it, I didn't know I could Rx a leg. Sure, you are a doctor, right? Just supply them with guidance on proper clinical note. Best in dogotal form so that they can copy paste into their note. Boom, done.
5. Unfortunately the surgeon could argue that he was looking out for the best interest of the patient. So nothing really can be done in regards to the surgeon. just get the referral from their primary care or PMR doctor
6. I would help patient find a PM&R or primary physician to work with them and you. Obviously if that surgeon's hand is forced they won't be giving good documents.
7. I would suggest this patient be evaluated by a physiatrist and you should then work with that doc to provide the most appropriate prosthesis
8. It would be the state medical licensing/review board.
9. Although these things are controlled on the state level, I find it very hard to believe that this could possibly be legal in TN. It would never fly here in California.
10. Is the patient on Medicare? If so, call them. If not, call your state insurance commissioner. There also might be an online link for the board of medicine ethics Dept. Finally does the patient have a primary care doctors h could ask for the Rx?
11. File a complaint with the department of Insurance. It's the patient's provocative not the doctor's.
12. I heard a similar story in the Chicago area. Have you talked with the primary care physician?
13. Surgeon doesn’t have to write the order and you’ll want to have a long term relationship with the pcp anyway for down the road.
14. Any doc can sign the Rx. If he has a family practice doctor or anyone else he has a good relationship with use them. When you are done take video to the Surgeon and start developing the relationship there.
15. I would suggest sending the Medicare Dear Physician(s) letter via overnight signature required with DWO and request for notes. While they are contemplating the letter see if the patient will go to another doctor for the referral.
16. He should file with the AMA and insurance commissioner or Medicare depending on where his insurance is.
17. The patient should call the 800# on the back of his insurance card. He might also see if the surgeon is a part owner of the facility he usually uses, thereby violating the Stark law. Even if he receives a referral fee, rather than owning part of the facility, in some states and with some insurance, that is a violation. If the patient doesn’t do the complaining, there is little you can do. Except suggest the pt get the Rx from the primary care doctor. That might work. Without an Rx your hopes of reimbursement are close to 0.
18. Hi Bonni..I don't know where your patient would file a complaint other than the state board or hospital but surely he could simply seek a second opinion from an orthopedist, another surgeon, or even his internist correct? After all he needs a prosthesis so there would be nothing wrong with firing his doctor and establishing with another. This doctor could then prescribe a prosthesis.
19. First I suggest the patient see his/her primary care physician for the Order and move on!
Secondarily, your state medical society has a grievance process.
20. Just a thought… but this is rather a unique opportunity. Please get this in writing from the surgeon’s office.
If this is a Medicare patient, I’d suggest getting your congressperson to send someone from their office down to inquire if they are interfering with patients’ right to choose their own provider and would it be helpful if their office reviewed all Medicare provider guidelines and ensured compliance…or something equally effective and unexpected like this.
21. You may want to point the patient to the Tennessee medical licensing board. They have a complaint process. Not sure how this type of situation would be viewed/handled, but worth the effort I think. Here is the link to the TN Medical Board of Examiners complaint page:
22. Had a similar scenario in that the surgeon wanted a patient to have a particular microprocessor knee, foot & suspension but on eval she was a better fit for another setup. When I explained my rationale the surgeon absolutely refused to consider changing his very specific/way too detailed & mostly ill-advised initial order. Turns out the prosthetic provider he normally uses ONLY uses the one style MPK & is very cookie cutter with all their components choices so this is all the surgeon prescribes. I had a very detailed discussion with the patient trying to be as impartial as possible & explained the functional pros & cons of the Rx'd device vs other options. She was open & willing to learn. Suggested she get another opinion & see a Physiatrist in the area who works with a lot of prosthetic rehab patients. I left her go in there cold- I didn't give the Physiatrist any information ahead of time & did not attend. The Physiatrist absolutely agreed that the surgeon's choice of knee, foot & suspension were not appropriate for her situation & provided her with another Rx. The patient followed the Physiatrist recommendation & ended up a very successful prosthetic user.
The surgeon doesn't need to be the one who writes the order, in fact, our surgeons no longer do because of all the documentation requirements. They will write for shrinkers with a notation that is ok to begin prosthetic intervention. Patients see a physiatrist or their PCP for their prosthetic needs.
Remember, it's the patient's choice! They have the right to go for 2nd opinions & obtain an Rx from another physician. Not sure Doctors have a right to say that they prefer to use this or that company...about 15 yrs ago all of our docs & rehabs stopped referring to a specific provider & started providing only prosthetic provider's pamphlets & suggesting patient interview each company & make their choice. Call the state board & inquire.
23. They should complain to their insurance company. They should also have a different doctor write their order, their PCP or a physiatrist.
24. If the patient is going to complain they could definitely contact their insurance company, who will get in contact with the surgeon for an explanation. We had Humana call because a patient said we were taking too long. Turned out the patient never called us saying he had issues and when we did reach out to him he never followed up, but I digress. If the surgeon is part of a group they could definitely complain to the group, hospital or parent company, but it might be difficult to get that information on their own.
The patient could also go to their own PCP or any MD/DO to have a prosthetic evaluation done and have the script written from them. It does not have to be the surgeon. Also, I've had plenty of surgeons say they didn't want to write the Rx at all because they were there specifically for the surgery and didn't feel comfortable evaluating a patient for prosthetic needs. Hopefully some of that works. Sounds like you're doing your all to get this patient the care they deserve. Keep on being awesome.
25. We went through the same thing several times. Come to find out, the other prosthetist had a cousin that worked for this vascular group. I'm fairly sure there are kickbacks going on with this provider but it's hard for any of us( several O&P companies have all complained) to prove. So I just tell
the patients to call Medicare and also call the OIG and file a complaint I think it means more when patients call and file a complaint. When it's a provider calling it seems like we are just complaining about the other provider getting more business than us. In my case I don't really blame the other prosthetist, who wouldn't want all the business. It's a different story if he is giving kickbacks. I strongly disagree with doctors not giving patients the right to go where they want to go, especially when they have had some very bad experiences with the other provider. So in my case I have urged patients to call and file a complaint and the OIG seems to be working on it. It does take a long time for them to investigate. If they get enough complaints they will investigate the financial relationships between the doctor and prosthetist to look for kickbacks. I'm pretty sure in my case they will end up getting this provider for kickbacks to doctor, therapists and home health workers. Time will tell, but at least they are looking into it. In your case, have the patients call and write about their complaints. Medicare doesn't do much about complaints, but the OIG seems to actually look into them.
26. The patient can go anywhere he wants despite whose Rx pad the Rx is written on. Dr cannot force him to go to a particular facility. I would call insurance company.
27. Have the patient see her primary and get the rx.
28. I came across you post. We run into this all the time. You are right it is not illegal. However, the prescription does not have to come form he surgeon. We are sending our patients to an independent PM&R doctor for the evaluation and prescription. Your patient can choose where they go for any of their care. Including their doctor who would write a prescription for them. I hope this helps.
1. Send the patient to his PCP to get an Rx and documentation and bypass the surgeon all together.
2. Is there an insurance complaint line?
3. Find different doctor to sign Rx and document- done.
4. Take your patient to a physiatrist. They are best ever resource for good notes and Rx. You always should have physiatry available for referral. Gods, even a family doc will write it. Some get kick out of it, I didn't know I could Rx a leg. Sure, you are a doctor, right? Just supply them with guidance on proper clinical note. Best in dogotal form so that they can copy paste into their note. Boom, done.
5. Unfortunately the surgeon could argue that he was looking out for the best interest of the patient. So nothing really can be done in regards to the surgeon. just get the referral from their primary care or PMR doctor
6. I would help patient find a PM&R or primary physician to work with them and you. Obviously if that surgeon's hand is forced they won't be giving good documents.
7. I would suggest this patient be evaluated by a physiatrist and you should then work with that doc to provide the most appropriate prosthesis
8. It would be the state medical licensing/review board.
9. Although these things are controlled on the state level, I find it very hard to believe that this could possibly be legal in TN. It would never fly here in California.
10. Is the patient on Medicare? If so, call them. If not, call your state insurance commissioner. There also might be an online link for the board of medicine ethics Dept. Finally does the patient have a primary care doctors h could ask for the Rx?
11. File a complaint with the department of Insurance. It's the patient's provocative not the doctor's.
12. I heard a similar story in the Chicago area. Have you talked with the primary care physician?
13. Surgeon doesn’t have to write the order and you’ll want to have a long term relationship with the pcp anyway for down the road.
14. Any doc can sign the Rx. If he has a family practice doctor or anyone else he has a good relationship with use them. When you are done take video to the Surgeon and start developing the relationship there.
15. I would suggest sending the Medicare Dear Physician(s) letter via overnight signature required with DWO and request for notes. While they are contemplating the letter see if the patient will go to another doctor for the referral.
16. He should file with the AMA and insurance commissioner or Medicare depending on where his insurance is.
17. The patient should call the 800# on the back of his insurance card. He might also see if the surgeon is a part owner of the facility he usually uses, thereby violating the Stark law. Even if he receives a referral fee, rather than owning part of the facility, in some states and with some insurance, that is a violation. If the patient doesn’t do the complaining, there is little you can do. Except suggest the pt get the Rx from the primary care doctor. That might work. Without an Rx your hopes of reimbursement are close to 0.
18. Hi Bonni..I don't know where your patient would file a complaint other than the state board or hospital but surely he could simply seek a second opinion from an orthopedist, another surgeon, or even his internist correct? After all he needs a prosthesis so there would be nothing wrong with firing his doctor and establishing with another. This doctor could then prescribe a prosthesis.
19. First I suggest the patient see his/her primary care physician for the Order and move on!
Secondarily, your state medical society has a grievance process.
20. Just a thought… but this is rather a unique opportunity. Please get this in writing from the surgeon’s office.
If this is a Medicare patient, I’d suggest getting your congressperson to send someone from their office down to inquire if they are interfering with patients’ right to choose their own provider and would it be helpful if their office reviewed all Medicare provider guidelines and ensured compliance…or something equally effective and unexpected like this.
21. You may want to point the patient to the Tennessee medical licensing board. They have a complaint process. Not sure how this type of situation would be viewed/handled, but worth the effort I think. Here is the link to the TN Medical Board of Examiners complaint page:
22. Had a similar scenario in that the surgeon wanted a patient to have a particular microprocessor knee, foot & suspension but on eval she was a better fit for another setup. When I explained my rationale the surgeon absolutely refused to consider changing his very specific/way too detailed & mostly ill-advised initial order. Turns out the prosthetic provider he normally uses ONLY uses the one style MPK & is very cookie cutter with all their components choices so this is all the surgeon prescribes. I had a very detailed discussion with the patient trying to be as impartial as possible & explained the functional pros & cons of the Rx'd device vs other options. She was open & willing to learn. Suggested she get another opinion & see a Physiatrist in the area who works with a lot of prosthetic rehab patients. I left her go in there cold- I didn't give the Physiatrist any information ahead of time & did not attend. The Physiatrist absolutely agreed that the surgeon's choice of knee, foot & suspension were not appropriate for her situation & provided her with another Rx. The patient followed the Physiatrist recommendation & ended up a very successful prosthetic user.
The surgeon doesn't need to be the one who writes the order, in fact, our surgeons no longer do because of all the documentation requirements. They will write for shrinkers with a notation that is ok to begin prosthetic intervention. Patients see a physiatrist or their PCP for their prosthetic needs.
Remember, it's the patient's choice! They have the right to go for 2nd opinions & obtain an Rx from another physician. Not sure Doctors have a right to say that they prefer to use this or that company...about 15 yrs ago all of our docs & rehabs stopped referring to a specific provider & started providing only prosthetic provider's pamphlets & suggesting patient interview each company & make their choice. Call the state board & inquire.
23. They should complain to their insurance company. They should also have a different doctor write their order, their PCP or a physiatrist.
24. If the patient is going to complain they could definitely contact their insurance company, who will get in contact with the surgeon for an explanation. We had Humana call because a patient said we were taking too long. Turned out the patient never called us saying he had issues and when we did reach out to him he never followed up, but I digress. If the surgeon is part of a group they could definitely complain to the group, hospital or parent company, but it might be difficult to get that information on their own.
The patient could also go to their own PCP or any MD/DO to have a prosthetic evaluation done and have the script written from them. It does not have to be the surgeon. Also, I've had plenty of surgeons say they didn't want to write the Rx at all because they were there specifically for the surgery and didn't feel comfortable evaluating a patient for prosthetic needs. Hopefully some of that works. Sounds like you're doing your all to get this patient the care they deserve. Keep on being awesome.
25. We went through the same thing several times. Come to find out, the other prosthetist had a cousin that worked for this vascular group. I'm fairly sure there are kickbacks going on with this provider but it's hard for any of us( several O&P companies have all complained) to prove. So I just tell
the patients to call Medicare and also call the OIG and file a complaint I think it means more when patients call and file a complaint. When it's a provider calling it seems like we are just complaining about the other provider getting more business than us. In my case I don't really blame the other prosthetist, who wouldn't want all the business. It's a different story if he is giving kickbacks. I strongly disagree with doctors not giving patients the right to go where they want to go, especially when they have had some very bad experiences with the other provider. So in my case I have urged patients to call and file a complaint and the OIG seems to be working on it. It does take a long time for them to investigate. If they get enough complaints they will investigate the financial relationships between the doctor and prosthetist to look for kickbacks. I'm pretty sure in my case they will end up getting this provider for kickbacks to doctor, therapists and home health workers. Time will tell, but at least they are looking into it. In your case, have the patients call and write about their complaints. Medicare doesn't do much about complaints, but the OIG seems to actually look into them.
26. The patient can go anywhere he wants despite whose Rx pad the Rx is written on. Dr cannot force him to go to a particular facility. I would call insurance company.
27. Have the patient see her primary and get the rx.
28. I came across you post. We run into this all the time. You are right it is not illegal. However, the prescription does not have to come form he surgeon. We are sending our patients to an independent PM&R doctor for the evaluation and prescription. Your patient can choose where they go for any of their care. Including their doctor who would write a prescription for them. I hope this helps.
Citation
Bonni Wilke, “Ethical question responses,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 5, 2024, https://library.drfop.org/items/show/209411.
