The Way I See It: Medicare is turning patients into informers

November 8, 2002

A misunderstanding about a flu shot almost landed this physician in trouble with the Feds.



Medicare is turning patients into informers


By Louis H. McCormick, MD
Family Physician/Franklin, LA

"There's an older gentleman at the window," the receptionist said over the intercom. "He says he was falsely charged and needs to go further with it."

Falsely charged? Further where? Bad outcomes and disgruntled patients get embedded in my memory. I didn't remember any of these encounters occurring recently.

"His name is Randall V. Kaitlin and he's only been here once," the receptionist added. (I'm not using his real name.)

It was a hectic Monday, and the waiting room was packed, but Mr. Kaitlin's concerns sounded urgent. I told my nurse to get his chart and bring him into the first available exam room.

"He couldn't stay," my nurse said. "He said you overcharged Medicare and his supplemental insurance by adding an office visit to the bill when all he received was a flu shot."

I felt a chill shoot through me as I imagined getting caught up in the federal bureaucracy. How long would it take to clear myself, and what would it cost me?

Because ours was one of the few offices that had flu vaccine that year, other doctors' patients, such as Mr. Kaitlin, had come to us. Our practice management consultant advised us that an office-visit charge was appropriate. Mr. Kaitlin's chart was properly documented, but I wondered how he would react to my explanation. I saw in his chart that he was an 81-year-old retired lieutenant colonel, which suggested he might not change his mind without a lot of persuasion. After finishing with the afternoon patients, I called him. "Hello, Col. Kaitlin, this is Dr. McCormick. I understand you have some concerns about your bill."

The colonel spoke in a crisp, authoritative voice. "Doctor, even though I didn't have to pay anything, it appears that my insurance was overcharged. Medicare asks us to help stop fraud by reporting items or services that were not received. I came for a flu shot, not a checkup."

I could hear papers being shuffled. The colonel was probably reading from his Medicare Summary Notice. Even though the medical record could prove that these accusations were groundless, it was painful to hear them verbalized by a patient who believed they were true.

I explained the appropriateness of the charges. "Colonel, would you want to go to a new doctor for a flu shot and not have him review your health history, medications, vital signs, and current status before administering the injection?"

"I appreciate thoroughness in anyone," the colonel replied.

Maybe we're getting somewhere, I thought. But I soon found out I was wrong.

"Your fee is much higher than what my doctor charges. This paper from Medicare has a toll-free number to call."

I explained that new patient charges are higher than fees for established patients. When I finished, I realized that without a doctor-patient relationship forged on trust, these explanations lacked credibility with Col. Kaitlin. In family practice, we learn a lot about our patients. But, since Col. Kaitlin wasn't a regular patient, all I knew about him was what I'd gleaned from the demographic page in his chart and the medical data from our brief office encounter.

What branch of the armed services had he been in? I wondered. Had he fought in World War II and Korea? What about hobbies? Interests? Kids? Grandkids? Great-grandkids? All Col. Kaitlin seemed to know about me was that I gave flu shots and a bad economic impression. He and I needed to find a common ground of understanding, but it wasn't going to occur by reciting factual data.

"Colonel, if I considered your questions about your bill unimportant, would I spend the time with you answering them?"

"No, you wouldn't."

"Well, I consider the time spent reviewing your medical data when you came in for a flu shot just as important."

There was a short pause. It sounded like papers were being crumpled.

"I've made up my mind, Doctor. I'm dropping the issue because there's no need to go any further with it. You're right. Taking time with me is important." Col. Kaitlin sounded pensive. "Time is a precious commodity that becomes more valuable as you get older."

I learned three lessons from my encounter with Col. Kaitlin. First, it's important to call patients when they have more than routine questions about their bills. Even though it adds another obligation to an already busy day, it gives the doctor a chance to clear up any confusion before a misunderstanding becomes a serious problem.

Second, tell patients to contact your office first if they have billing questions. At least Col. Kaitlin came by the office before contacting anyone else with his concerns. Medicare doesn't advise its members on the Summary Notice to follow this logical sequence. Asking patients in bold-faced print to notify Medicare immediately with questions about possible fraud and abuse makes doctors look automatically guilty.

Third, employing an expert in practice management to help ensure compliance with the government and other third party payers is worth the expense. Unfortunately, in today's climate, being up-to-date medically and using this knowledge to deliver quality health care isn't enough.

I now take one other precaution with new patients who come in for flu shots: During my exam, I inform them that they'll be charged for an office visit as well as the shot. I've had no one bother me about Medicare charges since Col. Kaitlin, and I believe it's because I took that extra minute to explain that.

There must be a better way to uncover possible Medicare fraud than by conscripting the elderly as mercenaries. But this is the reality. The best way to minimize the risk is to find a way to connect with patients on a human level, even if you see them only once. And if the relationship does become adversarial, try to put out the fire before it becomes a conflagration.


Louis McCormick. The Way I See It: Medicare is turning patients into informers. Medical Economics 2002;21:61.