I work as an RN care manager for a network that is contracted by our state Medicaid program. RNs are notified when a patient has been in the ED or hospital and follow up with them to make sure they have the knowledge and resources to prevent readmission. It is difficult for the patients to contact one of the physicians practice to make appointments and his patients have high ED use and readmissions. The practice has not been responsive to our care managers. Our company is aware of the issue, but is hesitant to contact this practice. The care managers, including myself, are assisting patients to change doctors so they can get proper care. What more can we do?
Nancy Brent replies:
It is unclear why the company for which you work is hesitant to approach the practice you are having difficulties with and whose patients cannot make necessary appointments. It seems this physician practice has not bought into the prevention framework upon which your company declares is its purpose. And, it seems the company is not doing so either, insofar as this physician practice is concerned.
Although you mentioned that the company is aware of the problem and trying to get patients to other physicians, has anyone spoken to the company’s legal counsel or attorney about this matter? More likely than not, the contract that governs the relationship between the company and Medicaid spells out the responsibilities of each party and what is to take place when those responsibilities are not met.
A second concern surrounding the contracted for requirements for this relationship is the fact that the physician is receiving money for his participation in the network but is not fulfilling his duties as specified in the contract. Could this be considered fraud? At the very least, the practice is not compliant with its obligations. Clearly, it is not behaving ethically.
Since the physician who owns/runs the practice is a licensed health professional in your state, he, and others who are licensed and participating in not being available for patients could be reported to the state regulatory agency. You should discuss this with the company’s legal counsel for guidance or, if you prefer, with a nurse attorney or attorney of your choice.
You can learn more about Medicaid fraud by visiting the U.S. Health and Human Service’s Office of the Inspector General website (http:oig.hhs/gov/fraud/medicaid-fraud-control-units/mfcu).
Medicaid Fraud and Control Units investigate and prosecute Medicaid fraud. There are units in 49 states and the District of Columbia. Other information that might be of interest to you in this situation is available on the website.