Midlevel attestations

[DocEspana]

"Hypothetical" question for the community that definitely isn't based on reality at all. Not at all.

So my place eased us out of flat rate payment and into RVU payment through multiple changes every few months over the last few years. What this lead to is the expected RVU system for our work, but also a system where we get full RVU credit for any midlevel chart that we sign as a level III attestation (that we full saw the patient, did our own independent evaluation, and a statement that we did more direct patient care than the midlevel did). We've been told to reserve this level of attestation just for admits, transfers, or patients we truly take over control of - which probably makes up around 15% (20% max) of our midlevels charts, since they self-select their patients to skew towards the dischargeable. We pool the RVUs from all of the other charts and divide them out evenly.

Anyway, in this situation every member of the group except 3 ends up with nearly identical amounts of level III attestations. The three exceptions are (1) two people who are adamantly against having to sign midlevel charts and only do so when they truly get actively involved in a case and they are sacrificing about $5-10 an hour because of it and (2) a single person who signs EVERY mid level chart with a canned statement that is as vague as can be but meets the criteria of technically saying he saw the patient, is choosing not to write any specifics because he agrees with everything the midlevel found on physical exam and history, and that he was more involved than they were in the patient care. He is (hypothetically) making $35-40 more per hour than everyone else (and about $50/hr more than the dudes not playing along at all) for it.

And lets say we hypothetically brought it up to him many times and he just plays dumb and says that he doesn't know why the billers feel thats a level III attestation and that he should 'get around to' changing that some time soon. And some people even went to the director who said "eh. not my job to tell him what to do" and so they went to the regional director who DID investigate and said that, as far as anyone from the company can tell, everything he is writing is true, he is seeing all his patients, and they commend him for going above and beyond by seeing 350-400 midlevel patients each month while everyone else can't prioritize the patients enough to see much more than 100ish per month. and they further commend him for doing it for the last 13 years so reliably (he has used this same attestation going back a loooong time) while the company has always struggled to get anyone else so motivated.

My question is: is my whole group just filled with stuck up do-gooders who don't realize everyone is okay with the grift? Like... should we all just get with the program and attest to the max? Also, for those who say 'oh he's taking such a legal risk.' IS HE? IS HE REALLY? I work in one of the most litigation happy locations in the US and I know two things 1) his only lawsuit ever was from a patient he saw himself 2) he's been doing this for 13 years and CMS hasn't come for him once or sent him any "practice deviance" letters in the mail and 3) if a patient my midlevel saw wants to sue it doesnt matter if my attestation says "this midlevel is nuts, told me nothing about this patient, and is practicing like a drunk mongoose with access to a medicine cabinet, I cannot endorse anything they just did" they're still going to name me in the suit and go after the person with the biggest malpractice coverage.

Obviously all hypothetically. But uh.... what should I hypothetically take from this?

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[Jabbed]

"Hypothetical" question for the community that definitely isn't based on reality at all. Not at all.

So my place eased us out of flat rate payment and into RVU payment through multiple changes every few months over the last few years. What this lead to is the expected RVU system for our work, but also a system where we get full RVU credit for any midlevel chart that we sign as a level III attestation (that we full saw the patient, did our own independent evaluation, and a statement that we did more direct patient care than the midlevel did). We've been told to reserve this level of attestation just for admits, transfers, or patients we truly take over control of - which probably makes up around 15% (20% max) of our midlevels charts, since they self-select their patients to skew towards the dischargeable. We pool the RVUs from all of the other charts and divide them out evenly.

Anyway, in this situation every member of the group except 3 ends up with nearly identical amounts of level III attestations. The three exceptions are (1) two people who are adamantly against having to sign midlevel charts and only do so when they truly get actively involved in a case and they are sacrificing about $5-10 an hour because of it and (2) a single person who signs EVERY mid level chart with a canned statement that is as vague as can be but meets the criteria of technically saying he saw the patient, is choosing not to write any specifics because he agrees with everything the midlevel found on physical exam and history, and that he was more involved than they were in the patient care. He is (hypothetically) making $35-40 more per hour than everyone else (and about $50/hr more than the dudes not playing along at all) for it.

And lets say we hypothetically brought it up to him many times and he just plays dumb and says that he doesn't know why the billers feel thats a level III attestation and that he should 'get around it' changing that some time soon. And some people even went to the director who said "eh. not my job to tell him what to do" and so they went to the regional director who DID investigate and said that, as far as anyone from the company can tell, everything he is writing is true, he is seeing all his patients, and they commend him for going above and beyond by seeing 350-400 midlevel patients each month while everyone else can't prioritize the patients enough to see much more than 100ish per month. and they further commend him for doing it for the last 13 years so reliably (he has used this same attestation going back a loooong time) while the company has always struggled to get anyone else so motivated.

My question is: is my whole group just filled with stuck up do-gooders who don't realize everyone is okay with the grift? Like... should we all just get with the program and attest to the max? Also, for those who say 'oh he's taking such a legal risk.' IS HE? IS HE REALLY? I work in one of the most litigation happy locations in the US and I know two things 1) his only lawsuit ever was from a patient he saw himself 2) he's been doing this for 13 years and CMS hasn't come for him once or sent him any "practice deviance" letters in the mail and 3) if a patient my midlevel saw wants to sue it doesnt matter if my attestation says "this midlevel is nuts, told me nothing about this patient, and is practicing like a drunk mongoose with access to a medicine cabinet, I cannot endorse anything they just did" they're still going to name me in the suit and go after the person with the biggest malpractice coverage.

Obviously all hypothetically. But uh.... what should I hypothetically take from this?

I’m not sure in what way your individual group’s reimbursement for midlevel charts differs from the general CMS guideline regarding split-shared decision-making.

I normally just dictate that I was responsible for the medical decision-making and then document a blurb to that affect “Patient with RLQ abdominal pain. WBC 12k. CT findings of epiploic appendagitis. Abdomen remained soft and benign. Tolerating PO. Pain controlled. Instructed to follow up with PCP and to return to the ED with any new or worsening symptoms.”

Physically seeing the patient is not a pre-requisite. MDM can occur from just looking at data and discussion with your midlevel.

If you’re talking about carte blanche signing charts for patients that you were not even aware of or not even in it hospital for… don’t do that.

 

[bravotwozero]

Attest to the max and snag them rvus

 

[DocEspana]

I’m not sure in what way your individual group’s reimbursement for midlevel charts differs from the general CMS guideline regarding split-shared decision-making.

I normally just dictate that I was responsible for the medical decision-making and then document a blurb to that affect “Patient with RLQ abdominal pain. WBC 12k. CT findings of epiploic appendagitis. Abdomen remained soft and benign. Tolerating PO. Pain controlled. Instructed to follow up with PCP and to return to the ED with any new or worsening symptoms.”

Physically seeing the patient is not a pre-requisite. MDM can occur from just looking at data and discussion with your midlevel.

If you’re talking about carte blanche signing charts for patients that you were not even aware of or not even in it hospital for… don’t do that.

Not any more. There was a not too subtle update from January 2022 and very subtle update from January 2023 to CMS's opinion on this. In 2022 they said that you can choose to DOCUMENT only the MDM, but that documentation needs to come with a statement that implies you did, in fact, have a face to face interaction with the patient - but they'll take your word for it. In 2023 they updated that further that the above is no longer enough and that CMS will, when it does reviews, decide who actually did most of the face-to-face interacting and will use your documentation vs the midlevels documentation to make that decision. Being face-to-face at all is not enough, you need to be MORE face-to-face than the midlevel. Which most people interpreted as 'midlevel charts are going to get midlevel billing unless the physician writes their own note that is as detailed, if not more, than the midlevel note', but reports from places that have been audited suggests that saying something akin to "I did everything the midlevel did and agree with every last element of it, and am not double-documenting due to redundancy..... but also I did this one extra thing" counts. Even now in early may its sort of fuzzy how this is being enforced because we spent years fighting this off and thought 2022's half-change was going to be the final outcome, but they tweaked it again in 2023.

all of this is a sort of tangential side note. My RVU system isn't based on CMS's billing rules except to say that the RVUs a chart DOES accumulate will either be assigned by my company solely to 1 doctor or pooled between all the doctors based on if we make it a level III attestation or not. That's what my contract says. Which, mind you, level I, II, and III is an outdated phenomenon since January 2023 - but as it is still built into our contract, it is still how we get paid. And this one theoretical gentleman is 100% percenting his midlevel charts even after the official emails from our company say to please not do that - the unofficial conversations held by phone call suggest they *love* that he does this.

 

[Pudortu]

Can you give us the attestation that your colleague uses? It doesn’t make sense how he can be vague and get all the midlevel RVUs. Has this worked since 2023 started with its new documentation requirements?

 

[DocEspana]

Can you give us the attestation that your colleague uses? It doesn’t make sense how he can be vague and get all the midlevel RVUs. Has this worked since 2023 started with its new documentation requirements?

yes. Thats why I'm bringing it up. He was complaining that his pay went down with the 2023 changes compared to 2022 and was complaining about his hourly pay only being only "three...." and trailed off, when everyone else's hourly pay starts with 2. So a bunch of us sat down and looked at the pay metrics (which we always had access to but never though to actually check) and he makes so much more than anyone else in the group all while seeing fewer patients than (almost) anyone else in the group - because hes listed as seeing hundreds of more midlevel patients on his own than anyone else. We knew forever he attested on evrryone and that he benefitted from it - but never realized it was to the tune of $50+ per hour over everyone else.

I'll find the attestation sometime soon.

 

[GonnaBeADoc2222]

Hmmm...sounds similarly annoying as the boomers who grift off my system here. Not as fraudy, but equally bull****

 

[RustedFox]

I see that we work for the same CMG.

Here on the other coast, our RVU component isn't very big; but yeah - I know about the three levels of charting attestation that you're talking about (notice in Meditech, they're listed 1-3-2, in order of increasing involvement: pay attention).

Personally, I simply choose the attestation that testifies what I actually did.

 

[BoardingDoc]

Not any more. There was a not too subtle update from January 2022 and very subtle update from January 2023 to CMS's opinion on this. In 2022 they said that you can choose to DOCUMENT only the MDM, but that documentation needs to come with a statement that implies you did, in fact, have a face to face interaction with the patient - but they'll take your word for it. In 2023 they updated that further that the above is no longer enough and that CMS will, when it does reviews, decide who actually did most of the face-to-face interacting and will use your documentation vs the midlevels documentation to make that decision. Being face-to-face at all is not enough, you need to be MORE face-to-face than the midlevel. Which most people interpreted as 'midlevel charts are going to get midlevel billing unless the physician writes their own note that is as detailed, if not more, than the midlevel note', but reports from places that have been audited suggests that saying something akin to "I did everything the midlevel did and agree with every last element of it, and am not double-documenting due to redundancy..... but also I did this one extra thing" counts. Even now in early may its sort of fuzzy how this is being enforced because we spent years fighting this off and thought 2022's half-change was going to be the final outcome, but they tweaked it again in 2023.

all of this is a sort of tangential side note. My RVU system isn't based on CMS's billing rules except to say that the RVUs a chart DOES accumulate will either be assigned by my company solely to 1 doctor or pooled between all the doctors based on if we make it a level III attestation or not. That's what my contract says. Which, mind you, level I, II, and III is an outdated phenomenon since January 2023 - but as it is still built into our contract, it is still how we get paid. And this one theoretical gentleman is 100% percenting his midlevel charts even after the official emails from our company say to please not do that - the unofficial conversations held by phone call suggest they *love* that he does this.

This is not correct.

The "substantive portion" of the visit now being defined by who spends the most time with the patient has been pushed back to 2024. You don't need to attest to spending more time with the patient this year provided that you say that you provided the substantive portion of the decision making.

Claim everyone. You're going to get sued for any of their **** ups regardless of whether or not you saw the patient. Get paid.

We're still trying to figure out how we're going to deal with this next year. The only solution we have at the moment is to have midlevels only see patients who aren't on medicare so we can skirt this new BS rule.

Reference: Calendar Year (CY) 2023 Medicare Physician Fee Schedule Final Rule | CMS

Relevant quote: "As finalized, clinicians who furnish split (or shared) visits will continue to have a choice of history, or physical exam, or medical decision making, or more than half of the total practitioner time spent to define the “substantive portion” instead of using total time to determine the substantive portion, until CY 2024. "

 

[DocEspana]

This is not correct.

The "substantive portion" of the visit now being defined by who spends the most time with the patient has been pushed back to 2024. You don't need to attest to spending more time with the patient this year provided that you say that you provided the substantive portion of the decision making.

Claim everyone. You're going to get sued for any of their **** ups regardless of whether or not you saw the patient. Get paid.

We're still trying to figure out how we're going to deal with this next year. The only solution we have at the moment is to have midlevels only see patients who aren't on medicare so we can skirt this new BS rule.

Reference: Calendar Year (CY) 2023 Medicare Physician Fee Schedule Final Rule | CMS

Relevant quote: "As finalized, clinicians who furnish split (or shared) visits will continue to have a choice of history, or physical exam, or medical decision making, or more than half of the total practitioner time spent to define the “substantive portion” instead of using total time to determine the substantive portion, until CY 2024. "

Oh nice. As of september/october (2022) they were still saying they were going to roll it out this year in january. Glad to see they kicked it down the can another year (you seem to be connected, so you probably knew originally this was planned for 2022). Im surprised I missed that, but happy to read it. I'm usually the one who has to educate my coworkers on these change.

 

[DocEspana]

What I'm gathering is about 66% support for "don't be so uptight and get that money"

 

[valianteffort]

I work in an RVU shop as well, 100% paid off of this. Below is what we use. Almost everyone is a 2 for me but if i am understanding correctly, I am getting 100% RVU for a 4 noted below and only 40% of the RVU for a 2. Somewhere inbetween for a 3. My hourly pay can vary almost 100 per hour over a whole month span depending on if i had more 4's vs more 2's which ends up being over 10k a month for normal hours. It is a huge difference, so I will always try to see the admits/critical care patients under them. I don't feel comfortable putting a 4 on everyone however as although I am still 100% liable, it is still medical fraud to say I saw everyone 'walking out the door' and that was enough.


1 - ATTENDING CO-SIGN: I was available to render services if needed but did not directly participate in the care of this patient.
2 - ATTENDING ATTESTATION OF APP WITH CASE DISCUSSION: I reviewed the patient's care with the Advanced Practice Provider and agree with the diagnosis and care plan.
3 - ATTENDING ATTESTATION WITH FACE TO FACE IN ED COURSE: I reviewed the patient's care provided by the Advanced Practice Provider and agree with the diagnosis and care plan. I personally saw the patient and performed a substantive portion of the visit including aspects of the history, physical exam, and medical decision making: SEE ED COURSE FOR FINDINGS.
4 - ATTENDING ATTESTATION WITH FACE TO FACE: I reviewed the patient's care provided by the Advanced Practice Provider and agree with the diagnosis and care plan. I personally saw the patient and performed a substantive portion of the visit including aspects of the history, physical exam, and medical decision making. My face-to-face evaluation shows: ***

 

[Rekt]

Crazy. I’d easily take a 10/$ hour hit to never be responsible for mid level charts. Surprised that’s worth it to you.

 

[DocEspana]

Crazy. I’d easily take a 10/$ hour hit to never be responsible for mid level charts. Surprised that’s worth it to you.

Still responsible. Our name is still on the chart and the midlevels *write it* on there and the company demands we at least close (sign) the chart. Florida just gives us the option to sign it with zero comment. But no one has ever heard of a lawsuit stopping at the hospital and midlevel because the physician only 'signed' the chart and did nothing else. Sounds like the quickest way to a settlement by your insurance ever since they will want to just move on from that suit rather than have you argue, on the record, that you never saw the patient - so that the other side can argue "and maybe if you did, the outcome would have been better."

The question is just whether saying you saw the sick ones (which you probably did) is worth $10 an hour and saying you saw the *not* sick ones is worth another $35-40 an hour.

 

[DocEspana]

Can you give us the attestation that your colleague uses? It doesn’t make sense how he can be vague and get all the midlevel RVUs. Has this worked since 2023 started with its new documentation requirements?

Here is the attestation:

I have participated in this patient's care as follows: All levels of evaluation and management services.
Personally performed: Medical decision making
Case discussed with physician assistant/nurse practitioner: Yes.
I agree with the history and physical exam provided by the physician assistant/nurse practitioner with the following exceptions: None.
I agree with the evaluation and management services provided by the physician assistant/nurse practitioner with the following exceptions: None.
I agree with the interpretation of studies documented by the physician assistant/nurse practitioner with the following exceptions: None.
Of note: I performed the substantive portion of the visit and I had face-to-face time with the patient.

It is just thrown on every chart with his name on it (and occasionally accidentally on charts assigned to someone else) as an independent note with only the above macro in it. I fully admit - I'm coming around to this idea that he has done this (with minor tweaks as billing changes) for over a decade without issue - maybe get the RVU while the RVU is worth getting. Someone else said that they get 100% if they attest a certain way and like 40% of they attest a different way. We get 100% for this but 8.3% (essentially. since the RVUs become pooled) if we dont rise to this level. He's rising to this level on every chart, so hes getting the money and depriving me of my chunk of the 8.3% on all of his outpatient midlevel charts. Maybe the move is in just accepting risk is unavoidable but I'm passing up on money by being... you know... ethical.

 

[RustedFox]

I would be inclined to sign for a higher level if my PLPs could put together a coherent chart.
Reading them is awful; they don't take even a hot second to glance thru their HPI and correct errors.
Then, it comes to me - and I actually read it - and I am left saying to myself: "lazy".

 

[Backpack234]

Does anyone else find these robotic charting phrases really strange?

I’ll write something like “i evaluated patient alongside the app. Labs showed c y z. Recommend x y z” and then let the biller/coder figure out the level.

But I’ve noticed an increase in charts like this

“Did I supervise the NP: yes
Charts reviewed: 1
Labs ordered: 2
Outside consults placed: 2
Decision to admit: yes”

I see why this happens now with the new charting/billing system but it feels like an old school AI wrote it

 

[hoot504]

Does anyone else find these robotic charting phrases really strange?

I’ll write something like “i evaluated patient alongside the app. Labs showed c y z. Recommend x y z” and then let the biller/coder figure out the level.

But I’ve noticed an increase in charts like this

“Did I supervise the NP: yes
Charts reviewed: 1
Labs ordered: 2
Outside consults placed: 2
Decision to admit: yes”

I see why this happens now with the new charting/billing system but it feels like an old school AI wrote it

It’s not poetry bro.

 

[Tenk]

For $50 an hour I would attest a lot of things too.

 

[thegenius]

Still responsible. Our name is still on the chart and the midlevels *write it* on there and the company demands we at least close (sign) the chart. Florida just gives us the option to sign it with zero comment. But no one has ever heard of a lawsuit stopping at the hospital and midlevel because the physician only 'signed' the chart and did nothing else. Sounds like the quickest way to a settlement by your insurance ever since they will want to just move on from that suit rather than have you argue, on the record, that you never saw the patient - so that the other side can argue "and maybe if you did, the outcome would have been better."

The question is just whether saying you saw the sick ones (which you probably did) is worth $10 an hour and saying you saw the *not* sick ones is worth another $35-40 an hour.

I think what he's saying is he would easily give up $10/hr if he were never the supervising physician on the charts. There's more to it than just giving up the money, it would have to be set up and documented within the group who is the supervising doc.

I would pay double, perhaps triple that.

 

[CoolDoc1729]

Does anyone else find these robotic charting phrases really strange?

I’ll write something like “i evaluated patient alongside the app. Labs showed c y z. Recommend x y z” and then let the biller/coder figure out the level.

But I’ve noticed an increase in charts like this

“Did I supervise the NP: yes
Charts reviewed: 1
Labs ordered: 2
Outside consults placed: 2
Decision to admit: yes”

I see why this happens now with the new charting/billing system but it feels like an old school AI wrote it

I do but my boss hammer email/texts me if there’s charts flagged that bounced back because I missed a component so I have an mdm macro with the things that tend to bounce back.
The rest of the chart I type out in conversational prose. I try to make sure each of my charts either has a funny or extraordinarily descriptive component, or used unusual words so they will be enjoyable for anyone to review and so I can remember which patient when they ask why I didn’t give 4700 ml of fluid 4 months ago. Today I reviewed a chart that said a patient “hailed from” an unknown ECF that didn’t send any paperwork .. lol

That macro above is BS if he isn’t actually seeing the patients ..

 

[Janders]

So part of the issue is him gaming the attestations. As Boarding doc said, you can modify the verbiage of your attestation to confirm with current guidelines and claim more patients without flat out lying.

But honestly the other part of the issue is the ridiculous way your group is divvying up the PA money.

You either get full credit for a full attest, or NO credit when they still sign your name to the chart and you have to cosign it. All those charts go into a pot and get divided evenly; but he is getting an equal share of a pot he put 0 patients into! Ridiculous! And why are they evenly divided? If you had 120 PA patients and I had 80, you deserve a bigger share!

In our system, all of the PA income rolls to the doc who saw the patient w/ the PA, regardless of the level of attestation. So if you just "cosign" and offer minimal attestation, you still get money... just potentially reimbursed at a lower rate than a shared visit with a fully MD involvement. So its your money, your supervision, your license, and your choice about how to attest and supervise the PAs (we encourage you to see every patient the PA sees, but if you don't want to you aren't forced).

Probably <<10% of PA patients do end up paying directly to the PA without any MD assigned (various silly insurance plans do that). We pool that money and apply it to group overhead, and its negligible vis-à-vis the total group budget.

 

[Janders]

So part of the issue is him gaming the attestations. As Boarding doc said, you can modify the verbiage of your attestation to confirm with current guidelines and claim more patients without flat out lying.

But honestly the other part of the issue is the ridiculous way your group is divvying up the PA money.

You either get full credit for a full attest, or NO credit when they still sign your name to the chart and you have to cosign it. All those charts go into a pot and get divided evenly; but he is getting an equal share of a pot he put 0 patients into! Ridiculous! And why are they evenly divided? If you had 120 PA patients and I had 80, you deserve a bigger share!

In our system, all of the PA income rolls to the doc who saw the patient w/ the PA, regardless of the level of attestation. So if you just "cosign" and offer minimal attestation, you still get money... just potentially reimbursed at a lower rate than a shared visit with a fully MD involvement. So its your money, your supervision, your license, and your choice about how to attest and supervise the PAs (we encourage you to see every patient the PA sees, but if you don't want to you aren't forced).

Probably <<10% of PA patients do end up paying directly to the PA without any MD assigned (various silly insurance plans do that). We pool that money and apply it to group overhead, and its negligible vis-à-vis the total group budget.

Granted we also pay the PA overhead based on how many cases you saw with the PAs, so part-time workers, or overnight-heavy workers... they pay less PA costs since they earn less PA money...

 

[sloh]

Jfc this all sounds so ****ing kafkaesque lmao. Wtf?!?

 

[DocEspana]

So part of the issue is him gaming the attestations. As Boarding doc said, you can modify the verbiage of your attestation to confirm with current guidelines and claim more patients without flat out lying.

But honestly the other part of the issue is the ridiculous way your group is divvying up the PA money.

You either get full credit for a full attest, or NO credit when they still sign your name to the chart and you have to cosign it. All those charts go into a pot and get divided evenly; but he is getting an equal share of a pot he put 0 patients into! Ridiculous! And why are they evenly divided? If you had 120 PA patients and I had 80, you deserve a bigger share!

In our system, all of the PA income rolls to the doc who saw the patient w/ the PA, regardless of the level of attestation. So if you just "cosign" and offer minimal attestation, you still get money... just potentially reimbursed at a lower rate than a shared visit with a fully MD involvement. So its your money, your supervision, your license, and your choice about how to attest and supervise the PAs (we encourage you to see every patient the PA sees, but if you don't want to you aren't forced).

Probably <<10% of PA patients do end up paying directly to the PA without any MD assigned (various silly insurance plans do that). We pool that money and apply it to group overhead, and its negligible vis-à-vis the total group budget.

Exactly. In the CMGs never ending quest to find a way to change us from flat pay to RVU and save money for themselves they installed a series of partial changes to pay which we always continued to make MORE money on. But it has, four changes in rules of reimbursement later, left us with remnants of all these systems layered on top of each other in a way that is.... Bizarre.... When used as one payment system.

So now I'm left wondering how much gaming a very stupid mid-level RVU system is worth to me. Seeing the opinions of others.

 

[DocEspana]

Reviving the thread to ask: anyone think there is going to be a spike on lawsuits by the end of the year over the new attestation wording. I work at two different sites and at both of them attestation rates have never been higher despite the wording being so.... Unrealistic. The CMG overlords (two different ones) have twisted our arms enough that we are actually doing it at incredibly high rates where I work, but I just get this feeling that this particular wording is going to drag doctors into more lawsuits.

Easy copout (though true) answer is that if you have a juicy malpractice coverage and are anywhere within 10 feet of the case you'll get named. But also, this new wording has to just look amazing for plaintiff attorneys as you either have proof the doctor is involved and culpable for patient care decisions or that they falsified documentation.

 

[emergentmd]

Been a MD director for 10+ years in big hospitals and FSERs who have APCs.

Usually 1 out of 10 will no way sign an APC chart. But in reality, they were the supervising doc so not sure what liability she was avoiding. If there was an APC lawsuit, APC will point to her as supervisor and then she has no legs to stand ob. Not like the APC will be holding the bag. Prob even looks worse b/c it shows derelict of supervision. Never made sense

8 out of 10 docs would just sign saying they didn't see the pt and avail. They lose 15% of billing for this.

The rare doc will document enough to get the 15%. CMG loves this doc b/c he increased revenue.

Now looking at the CMG higher ups, do you think they will kill the golden cow? They wish you all would do this and increase revenue. Now you are going to complain about the golden cow? Good luck on that being the marked man.

Either suck it up and do what he does or continue to be bitter that the is playing the game better than you are.

What you really need to worry about is when your pay goes down and they point to the complex opaque RVU system. You sir are looking down at lower payments b/c they know have a mechanism to screw you and keep more money.

Some docs do no CC ever, some do alot more. Its all about gaming the system.

 

[Groove]

Do you guys think refusing to attest a chart sufficiently protects you in a malpractice suit? So, let's say the APC orders got sent to you during a shift and you signed them but later found out that the APC missed something significant and you refused to attest or co-sign the note. You were never involved in the patient's care or even saw the patient. You forward it to the medical director who is technically listed as their supervising physician on their credentialing paperwork for the hospital. Anybody ever been personally involved or know of a case like that? Is refusing a co-signature/attestation protective?

 

[thegenius]

Do you guys think refusing to attest a chart sufficiently protects you in a malpractice suit? So, let's say the APC orders got sent to you during a shift and you signed them but later found out that the APC missed something significant and you refused to attest or co-sign the note. You were never involved in the patient's care or even saw the patient. You forward it to the medical director who is technically listed as their supervising physician on their credentialing paperwork for the hospital. Anybody ever been personally involved or know of a case like that? Is refusing a co-signature/attestation protective?

Nope.
If your state law is you must supervise your APC, then you are responsible for everything they do. Irrespective of whether you know what they performed, they spoke to you, what is documented, etc.

 

[Birdstrike]

edited

 

[comp1]

I think this is genuinely why most states have or are quickly moving to independent NP practice (27+ and rapidly growing). It reflects the reality of what is happening at the very least. NPs are not resident or med student trainees. Physicians should not have the same level of responsibility for their work.

 

[Groove]

Nope.
If your state law is you must supervise your APC, then you are responsible for everything they do. Irrespective of whether you know, they spoke to you, what is documented, etc.

Well, that's the problem. The state laws are nebulous in a lot of places. Where I'm at, NP don't have independent practice rights but only 20-30% of their charts have to be "reviewed" by a supervising physician. The definition of a supervising physician are also vague. In general, if you get very specific about it...it would be the doc who is on their credentialing paperwork for the hospital and they don't have to be physically present, only available by phone. Most of the time that's the FMD. There's no law in my case where the physically present doc must be the definitive supervising physician. I'm also not even sure why the docs are required to sign 100% of their charts. I'm not aware of any bylaw at my hospital requiring this and suspect it's more of a CMG requirement.

 

[Groove]

There's a clear precedent where I'm at of physicians that were proven to be absolutely not involved in an APC case, that they get dropped so I'm not even sure it really matters but who would want to co-sign a chart where they knew the APC missed something? How do you force a doc to sign a note like that?

 

[comp1]

It is indeed nebulous and is ultimately going to vary on the state law. NPs are generally independent when functioning in a federal facility. If your state legal oversight obligation of the NP is the same as that of an MD functioning as a medical director, ie you intermittently review charts for any sort of adverse patterns, it's not clear you're going to be any more liable than you would be with a MD. And indeed, this is how some states define oversight. Yes, you can be sued for anything at any time and yes, plaintiff lawyers will try to name everyone at the start, including the med students and housekeeping staff. I'm talking about who eventually gets the settlement attached to their name. If you actually have to cosign every piece of work that a NP generates, then yeah, you do actually have some responsibility. In the situation above, the cosigner would be responsible for alerting the NP to the errors or missing items and documenting that in an addendum, as they would be with a resident trainee. Of course, again, NPs are not trainees so it's very weird when they are treated as such indefinitely by state law. I think this will all get shaken out with independent practice rights.

 

[Birdstrike]

The midlevel concept works if:

1-You have the choice whether or not to work with them
2-You have the choice which to work with
3-You have the power to hire or fire based on performance
4-You have the time to supervise
5-You benefit in work load
6-You benefit financially

 

[thegenius]

Well, that's the problem. The state laws are nebulous in a lot of places. Where I'm at, NP don't have independent practice rights but only 20-30% of their charts have to be "reviewed" by a supervising physician. The definition of a supervising physician are also vague. In general, if you get very specific about it...it would be the doc who is on their credentialing paperwork for the hospital and they don't have to be physically present, only available by phone. Most of the time that's the FMD. There's no law in my case where the physically present doc must be the definitive supervising physician. I'm also not even sure why the docs are required to sign 100% of their charts. I'm not aware of any bylaw at my hospital requiring this and suspect it's more of a CMG requirement.

yea that could be. At this point it's all legal stuff and I for one don't want to be in that position. I'm in CA and basically I'm responsible for everything. If an APC is suturing a finger and nicks a tendon and the finger doesn't work properly afterwards, I'm responsible. If the APC says "fduck you" to a patient, I'm somehow responsible.

 

[thegenius]

There's a clear precedent where I'm at of physicians that were proven to be absolutely not involved in an APC case, that they get dropped so I'm not even sure it really matters but who would want to co-sign a chart where they knew the APC missed something? How do you force a doc to sign a note like that?

Well there's no forcing. It's a matter on whether you want a job. You can try to negotiate it out of your contract.
I know you know all of this.
I've had management be supportive of me when I asked an APC to bring back a patient for further eval

 

[comp1]

I'm always grateful when people list the state they are in because it really helps answer questions. NPs in CA will get full practice authority in 2026 ending this mess.

 

[southerndoc]

Do you guys think refusing to attest a chart sufficiently protects you in a malpractice suit? So, let's say the APC orders got sent to you during a shift and you signed them but later found out that the APC missed something significant and you refused to attest or co-sign the note. You were never involved in the patient's care or even saw the patient. You forward it to the medical director who is technically listed as their supervising physician on their credentialing paperwork for the hospital. Anybody ever been personally involved or know of a case like that? Is refusing a co-signature/attestation protective?

Probably would make it less defensible. Plaintiff counsel would argue if you didn't sign it, you knew something was wrong so you should've called the patient back. If the patient already had a bad outcome, they would say you're picking and choosing your charts.

 

[BoardingDoc]

The midlevel concept works if:

1-You have the choice whether or not to work with them
2-You have the choice which to work with
3-You have the power to hire or fire based on performance
4-You have the time to supervise
5-You benefit in work load
6-You benefit financially

Yep. I really like our PAs and enjoy working with them. That isn't a happy accident. It's because I'm fortunate enough to work somewhere where all of the above apply.

I've worked places where they don't.... and I don't.

 

[DocEspana]

Been a MD director for 10+ years in big hospitals and FSERs who have APCs.

Usually 1 out of 10 will no way sign an APC chart. But in reality, they were the supervising doc so not sure what liability she was avoiding. If there was an APC lawsuit, APC will point to her as supervisor and then she has no legs to stand ob. Not like the APC will be holding the bag. Prob even looks worse b/c it shows derelict of supervision. Never made sense

8 out of 10 docs would just sign saying they didn't see the pt and avail. They lose 15% of billing for this.

The rare doc will document enough to get the 15%. CMG loves this doc b/c he increased revenue.

Now looking at the CMG higher ups, do you think they will kill the golden cow? They wish you all would do this and increase revenue. Now you are going to complain about the golden cow? Good luck on that being the marked man.

Either suck it up and do what he does or continue to be bitter that the is playing the game better than you are.

What you really need to worry about is when your pay goes down and they point to the complex opaque RVU system. You sir are looking down at lower payments b/c they know have a mechanism to screw you and keep more money.

Some docs do no CC ever, some do alot more. Its all about gaming the system.

I will tell you that the *current* SCP model I work in, its not a 15% cut on that chart (thats what the CMG loses).... its like a 25% cut to your total paycheck as they will not give you any credit for midlevel charts unless you give them the full-fat signature. And we get RVUs at 100% crossover for midlevel charts we fully endorse, and at 0% for any other form of signature/ignoring the chart. Our midlevels represent like half of the patient we "see" in a day and our hourly pay is not so robust, so losing out on 100% of their RVUs for not signing every single chart as the 'i take responsibility for everything' is a massive chunk of our monthly pay. Pretty much everyone is the golden cow because they didn't pull any punches and told us we'd be taking the equivalent of a >$10k pay cut if we don't endorse those midelevel charts to their fullest extent and its an all-or-nothing payment for us.

thus why I say attestations have never been higher. Was on a call on thursday where they announced that in the ENTIRE ER for the month of december they had 6 midlevel charts that weren't 100% credit signed and they noted that "four of the six were charts where the attending stated they had concerns with the management and dont endorse the plan. so only two no-signs. Lets try to get that to zero!"

 

[DocEspana]

Nope.
If your state law is you must supervise your APC, then you are responsible for everything they do. Irrespective of whether you know what they performed, they spoke to you, what is documented, etc.

Florida nicely has it written into... something (idk if state law or board of medicine policy)... that physicians do not need to sign charts of midlevels. We do have to "sponsor" them as supervising physicians, but we dont have to attest to their notes themselves. I enjoy every time I take a new job that the CMG has to painfully but formally tell me that I have no legal responsibility to sign any midlevel chart, followed by tons of HR-approved speech about how they hope I'll go incredibly above and beyond legal minimums.

 

[emergentmd]

thus why I say attestations have never been higher. Was on a call on thursday where they announced that in the ENTIRE ER for the month of december they had 6 midlevel charts that weren't 100% credit signed and they noted that "four of the six were charts where the attending stated they had concerns with the management and dont endorse the plan. so only two no-signs. Lets try to get that to zero!"

Toxic