Records of several surgeries performed three years ago at the University of Toledo Medical Center will show those operations were completed without problems, but identifying the doctor who performed the operations could be more difficult.
A nonprofit firm that conducts medical billing for UTMC doctors also investigates mistakes among the 100,000 or so bills sent annually to government and private insurance companies. In 2009, the University of Toledo Physicians Clinical Faculty Inc. investigated the billing of surgeries for at least two doctors and ultimately issued some refunds, according to a confidential document obtained by The Blade.
“There was a concern about the billing of certain cases involving a new physician in OB/GYN. An investigation of the billing of surgeries in question involving the two physicians was completed,” stated the minutes from the Aug. 11, 2009, compliance committee meeting of the University of Toledo Physicians Clinical Faculty Inc.
Neither Dr. Jeffrey Gold, chancellor and vice president for biosciences and health affairs at UTMC, nor Bryan Pyles, executive director of the UT Physicians Clinical Faculty, would discuss the specifics of any cases. Both the university and the independent UT Physicians Clinical Faculty — which provides administrative support, billing, and collection services for physician services at the university — declined to release a copy of the meeting minutes. After more than a month and several requests from The Blade, Kevin Devaney, an attorney with Eastman & Smith Ltd., told the newspaper the document was not a public record.
“Specifically, the UTPCF compliance committee is ‘peer review committee’ ... and the records of any such committee are required to be held in confidence and are not subject to discovery,” Mr. Devaney wrote to a Blade editor last month.
He later said billing errors are unavoidable with “the sheer volume of claims that are submitted.”
Dr. Lloyd Jacobs, president of UTMC (the former Medical College of Ohio), said the university medical center requires absolute compliance with Medicare rules regarding the physical presence of the surgeon of record when billing.
“We scrupulously monitor this and look into every hint of noncompliance,” Dr. Jacobs said. “We believe we have been fully compliant for many years.”
The meeting minutes obtained by The Blade indicate that during that single month several concerns were raised about billing for doctors’ services for surgeries at which they were not present. It does not indicate that the incorrect billing was the result of mistakes within the complicated system of medical billing codes, misreading of notes taken on the surgeries, or something else.
“From the documentation, it is unclear which attending was actually scrubbed in for the surgery and which physician performed the surgery,” the meeting minutes said. “The compliance committee recommends that the one case in which the billing physician was not involved be refunded and re-billed under the correct name and that the other cases have sufficient concerns that they too be refunded.”
It said surgeries of Dr. Terrence Horrigan were audited back to July, 2008 “as to presence and assistant surgeons that are attending.” Dr. Horrigan could not be reached for comment.
“There are 13 surgeries that are being investigated,” the record said.
Another example cited in the meeting minutes showed another doctor not present for a surgery that was billed under his name.
“There was a concern brought to the committee that Dr. [Frederick] Cason performed surgery on May 18, 2009, and did not participate in the case. A review of medical records indicates he was the surgeon named in the medical records,” the meeting minutes said. The document said a resident dictated the surgical operative note and Dr. Cason authenticated it and it was billed.
“It was noted Dr. Cason was not present in the surgical suite at the time of the surgery. The surgery was refunded,” the document said.
At the time of that meeting, Dr. Cason had applied for a position at Louis Stokes Cleveland VA Medical Center, where he soon afterward became chief of surgical service. He is now a general surgeon in Kansas City.
Dr. Cason said he had no knowledge of the “investigation” by the UT Physicians Clinical Faculty.
“Billing errors like that in residency programs occur like that,” he said. “Sometimes a chief resident is allowed to do surgeries with some independence … or I was in the operation room but in the notes, it does not show up that I was there.”
Dr. Cason said it could have been that the wrong attending doctor was listed and that he was not the attending at all. He added that doctors at UTMC have nothing to do with billing for services.
The meeting minutes also mentioned a “Dr. Lane” — stating that his evaluation and management audit of 10 encounters was completed and that five had no documentation at all. Hospitals need that kind of documentation — which details the type of procedures — to ensure payment from insurance companies.
“Dr. Lane was met with and re-educated as [to] the documentation guidelines,” the meeting minutes said. UTMC employed more than one doctor with the last name “Lane” in 2009. UTMC officials again declined to elaborate, citing peer review confidentiality.
Dr. Gold, who sits on the Physicians Clinical Faculty board of directors, said the group’s compliance committee regularly deals with mistakes regarding billing.
“There is an endless number of tiny, technical opportunities for improvements that we identify — a computer glitch, a coding mistake, an overpayment or underpayment,” he said. “There is a back and forth overcharging [and] undercharging. I am not aware of an instance that would rise to a higher level.”
Dr. Gold also said he could recall some cases in which the documentation did not support what was in the chart for a particular case or vice versa.
“Every surgeon is not present for every surgery from beginning to end,” he said. “I might not be physically present in the operating room, but I would be available.”
Medical billing errors have been an issue nationwide for years. The Commonwealth Fund, a Washington-based nonprofit group focused on health-care research, released a report in December, 2010, that found medical billing errors negatively affect credit reports for about 14 million Americans.
Nora Johnson, former director of education and hospital billing compliance for Medical Billing Advocates of America, who lives in West Virgina, said the system of medical billing codes is complicated and is a breeding ground for errors.
“The system is set up to perpetuate errors ... If they don’t use those codes, they don’t get paid,” Ms. Johnson said.
She added: “Services not rendered is one of the most egregious fraud risks for hospitals and for providers ... I would say not everyone is going to be guilty.”
She said the coding comes from what is written by the doctor in the operative notes, and the coding defines the exact type of procedure.
The UT Physicians Clinical Faculty has about 70 people working within its on-campus office location and about 200 UTMC doctors are also employed through the nonprofit. Mr. Pyles, who has been the executive director for about a year, said the group has undergone several structural changes over the years, including when the former Medical College of Ohio was merged with UT.
Doctors are paid by UTMC for teaching and by the Physicians Clinical Faculty for “delivery of clinical health care,” Dr. Gold added.
According to UT’s audited financial statements for the fiscal year that ended on June 30, 2011, the University of Toledo Foundation and Physicians Clinical Faculty are “legally separate entities.”
“The Foundation and UTP-CF are discretely presented as component units of the university,” the financial statement states.
The Physicians Clinical Faculty’s 2010 federal tax returns list $74.1 million in total revenue and $73.7 million in expenses. The firm’s attorney, Mr. Devaney, said the 2011 returns were not complete because the organization had filed an extension.
The 2010 return listed Tammy Scarborough as the principal officer. She is the wife of Scott L. Scarborough, UT’s provost and executive vice president for academic affairs.
Contact Ignazio Messina at firstname.lastname@example.org or 419-724-6171 or on Twitter @IgnazioMessina.
Guidelines: Please keep your comments smart and civil. Don't attack other readers personally, and keep your language decent. Comments that violate these standards, or our privacy statement or visitor's agreement, are subject to being removed and commenters are subject to being banned. To post comments, you must be a registered user on toledoblade.com. To find out more, please visit the FAQ.