Monday, November 9, 2015

Pain Management Physicians' Treatment Plans And Records Are Being Reviewed With Great Scrutiny - How To Respond To Request For Records and Interview

Board certified pain management physicians are beginning to have records requested from the California Medical Board with greater frequency. In many cases, the Medical Board has requested them due to complaints from family members or pharmacists. 

It is critical to be prepared and handle any requests for records or interviews with great care and seek expert attorney and expert witness review at the earliest time. 

It is also important to review your office's systems and documentation standards now before any records are requested. Remember, if any complaint is made it is highly likely that records will be requested and patient charts are not usually perfectly documented and the standards 

What You Can Learn From One Pain Management Physician's Medical Board Case. 

Here is a sample case of a pain management physician that ended up in a Medical Board Accusation being filed against him for unprofessional conduct, gross negligence, repeated negligence, and excessively prescribing to a patient without a proper medical indication in violation of California Business and Profession Code Section 725, 2234(b)(c) or (d), and 2242(a) relating to several patients.  This was a highly trained and regarded physician in the field of pain management.

How did this case end up as an Accusation and what can you do to avoid a similar situation? 

1.  Documentation Issues - Especially With Long Term Patients. The pain management physician had treated each of the patients for over ten (10) years and as trust and time goes on, the documentation is not always as thorough as it is for short-term patients. Document the rationale for decreasing or increasing dosages or changing medications even if it is brief. Document the treatment plan with the objective for caring for the patient, treating the underlying condition causing the pain, and addressing the pain.

Ensure that there was a complete history obtained from the patient. If not done before, do it now. Obtain prior medical records to confirm patient's alleged prior treatment, injuries and medication. Look at the documentation from prior physicals. Were they thorough? If not, do another appropriate exam especially where there have been worsening symptoms, increased medications prescribed or failure to heal or reduce medications.  All diagnoses should be supported by the current records and/or prior medical records. Self-reporting of diagnoses by patients is not enough.

2.  Review of long-term patients for addiction and dependency issues. This is a sound practice, and document these consultations and medical decision making in the treatment plan. It is important to address the risk of dependency, addiction and abuse of opioid. If there are references to nonpharmacologic treatment recommendations (massage therapy, chiropractic treatment, cognitive behavior therapy, physical therapy, etc.) make sure that there are actual referrals and not simply template recommendations.

Monitor, monitor, and monitor. CURES should be regularly run for all patients in today's world.  Document the monitoring. Make it a part of the practice.  

If patient has had long-term use of opioid medications and/or has a high risk for abuse (prior addiction issues) refer the patient to an addiction specialist. Document it. Find providers you can refer to and document it.

3.  If the patient has failed a toxicology screen with the use of alcohol or other substances, document your response. Otherwise, it will be deemed a departure from the standard of care. If the patient has a repeated excuse such as exposure to hand sanitizers, document whether that is a credible excuse and take action.

4.  Be aware of red flags and document their existence and how treatment is being handled in light of them.  For example, if a patient reports pain levels that is inconsistent with actual functioning (claims cannot walk or sit for more than a minute or two but is driving to and from appointments and walking without assistance), address it in the records.  

If it is known that the patient is an addict, avoid prescribing controlled substances for non-therapeutic purposes (such as to satisfy an addiction). Document this and address. 

5.  If family members report addiction or abuse issues, document discussion with patient in chart and document any medical decision making on continued prescribing of pain medications and referrals to other physicians.

6.  Be very familiar with the patient charts before any Medical Board interview. In this case, the physician did not remember a letter from a family remember reporting abuse even though it was in the chart and he had referenced it in a letter to the insurance company. This appeared to be possibly deceptive rather than memory loss.

7.  Have an attorney and expert review your charts before any Medical Board interviews and have that expert hired by the attorney to preserve attorney-client work product. Having a second set of professional eyes is important.

8.  If you catch any documentation or procedure issues in your office in the requested files, make changes immediately so the Board can be notified that changes have been made and will not occur again.  

9.  If the patient has any accidents, blackouts, memory issues or personal problems (losing job, home, etc.) that could be attributed to use of pain medications, address these with the patient and document. Indicate any changes in the treatment plan. If you are being interviewed about that patient, be prepared to address these issues.

10.  The standard of care has tightened the past five (5) years. Review pain management contracts, consent forms and other standard forms that are signed by patients. Update if needed.  Get updated signatures if any are missing from existing patients.  

There will always be addicts and individuals who become dependent on opioids. The key is that physicians want to demonstrate that they are treating their pain and not enabling any dependency or addiction issues. 

This does not simply mean firing patients when a red flag issue arises but showing the medical decision making and treatment and having procedures in the office that can address these issues in a time-sensitive and medically appropriate way.

If your office receives a request for records, handle it appropriately. Most importantly, do not alter or add to the record. If there is need to explain the rationale in medical decision making, that can be done in a letter summarizing the records and treatment. Alteration of records is often treated more harshly than the documentation issue itself.

Posted by Tracy Green, Esq.
Office: 213-233-2260


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