how to report a patient for overuse

How do you deal with overuse and underuse of procedures?

There’s a broad public and professional education campaign called “Choosing Wisely” that includes a long list of “never do” procedures and tests and they all still get done. That’s because there’s no one thing to correct a specific overuse or underuse problem.

What is overuse of medical services?

Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem.

What are the effects of overuse of unneeded services?

Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health.

Can a physician refuse to authorize a patient to report?

Exceptions can be made if a physician reasonably believes that a patient’s refusal to authorize reporting is coerced and therefore does not constitute a valid informed treatment decision. Physicians should also protect patient privacy when reporting by disclosing only the minimum necessary information.

How do I report to CMS?

How to File a Complaint.CMS, on behalf of HHS, enforces HIPAA Administrative Simplification requirements.Go to ASETT.CMS.GOV.Upon logging in, click the "New Complaint" button on the welcome page.Click “Complaint Type” and select the issue you are reporting.More items...

How do you ask a patient if they are being abused?

How to AskDifferent patients may respond better to different approaches.Make sure to ask in a private environment and do not use family or friends as interpreters.See ethics and privacy section before you start discussion.Patients highly value compassion and the quality of being non-judgemental.

What do doctors do if they suspect abuse?

Action Step A physician who has a reasonable suspicion that a child has been subjected to physical or sexual abuse should immediately report to the appropriate child welfare agency. The signs and residual effects of physical abuse are often more apparent than those associated with sexual abuse.

What is considered Medicare abuse?

What Is Medicare Abuse? Abuse describes practices that may directly or indirectly result in unnecessary costs to the Medicare Program. Abuse includes any practice that does not provide patients with medically necessary services or meet professionally recognized standards of care.

What do nurses do if you suspect abuse?

If a nurse suspects abuse or neglect, they should first report it to a physician, nurse practitioner, or physician assistant. Notifying a supervisor may also be required, depending on the workplace. If the victim is with a suspected abuser, the exam should take place without that person in the room.

What can you do if someone is being mistreated?

How can I help someone who is being abused?Set up a time to talk. ... Let her know you're concerned about her safety. ... Be supportive. ... Offer specific help. ... Don't place shame, blame, or guilt on her. ... Help her make a safety plan. ... Encourage her to talk to someone who can help. ... If she decides to stay, continue to be supportive.More items...•

What are some basic rules for nurses to follow when assessing for violence?

Explanation: Nurses assessing for violence should perform assessment and screening only when the client is alone in a safe, private environment. The nurse needs to establish rapport and connection by showing interest in the client and by listening. The nurse also needs to demonstrate compassion, not judgment.

What are the nurse's ethical responsibilities for a client who is a victim of abuse neglect?

Under this principle, nurses have a duty to treat people with compassion and to respect the inherent worth and dignity of each individual. Victims of abuse have been violated in physical, sexual or emotional ways; nurses are expected to deliver care no matter how difficult or ugly the situation may be.

Which behavior could be reason to suspect abuse?

That's why it's vital to watch for red flags, such as: Withdrawal from friends or usual activities. Changes in behavior — such as aggression, anger, hostility or hyperactivity — or changes in school performance. Depression, anxiety or unusual fears, or a sudden loss of self-confidence.

What are the three examples Medicare uses to describe abuse?

Common types of abuse include: Billing for unnecessary services (services that are not medically necessary) Overcharging for services or supplies. Misusing billing codes to increase reimbursement.

What is an example of healthcare abuse?

Changing or forging an order or prescription, medical record, or referral form. Selling prescription drugs or supplies obtained under healthcare benefits. Providing false information when applying for benefits or services. Using Transportation Services to do something other than going for medical services.

What is billing abuse?

Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly intentionally misrepresented the facts to obtain payment.

Should you ask someone if they are being abused?

Ask Without Asking So, now you're worried. You want to do the right thing and be there for your friend or loved one, but asking them if their partner is abusive isn't going to always be met with the most grateful of responses.

Why do doctors ask if you've been abused?

Doctors want to know whether you feel safe and supported in your personal life. The CDC defines domestic violence, or intimate partner violence, as abuse or aggression that occurs in a personal relationship, whether the abuser is a spouse or dating partner, or the relationship is heterosexual or same-sex.

What is required of a nursing assistant if he suspects that a resident is being abused?

In a long-term care facility, any CNA who suspects abuse of a resident by either a family member or another professional caregiver should first report it to his or her supervisor.

Why do doctors ask you if you feel safe at home?

“Do you feel safe at home?” It can feel like a strange question to be asked when you've come in because you're having chest pain, or because you've cut your finger. But, doctors are supposed to ask – because this visit could be a brief window of opportunity to connect a victim to resources.

What to do when a patient is suspected of abuse?

Discuss any suspicion of abuse sensitively with the patient, whether or not reporting is legally mandated, and direct the patient to appropriate community resources.

How should physicians protect patient privacy when reporting?

Physicians should also protect patient privacy when reporting by disclosing only the minimum necessary information.

What is the opinion 8.10?

In Opinion 8.10, “Preventing, Identifying and Treating Violence and Abuse,” the Code explains that all patients may be at risk for interpersonal violence and abuse, which may adversely affect a patient’s health or ability to adhere to medical recommendations. Physicians, in light of their obligation to promote the well-being of patients, have an ethical obligation to take appropriate action to avert the harms caused by violence and abuse.

What is the abuse in the exam room?

Patients in your exam room may be experiencing one of a number of forms of abuse—domestic violence, human trafficking or other violence— and identifying those being abused can sometimes be tough.

How many victims of trafficking had contact with a health professional?

The authors noted research showing that 88% of victims had contact with a health professional while being trafficked, but none were identified or offered help in getting out of their situation during the medical encounter.

When is informed consent not required?

Obtain the patient’s informed consent when reporting is not required by law. Exceptions can be made if a physician reasonably believes that a patient’s refusal to authorize reporting is coerced and therefore does not constitute a valid informed treatment decision.

Is abuse rare in a normal family?

Not allow diagnosis or treatment to be influenced by misconceptions about abuse, including beliefs that abuse is rare, does not occur in “normal” families, is a private matter best resolved without outside interference, or is caused by victims’ own actions.

What are some examples of overdiagnosis?

There are multiple examples of overdiagnosis in the field of cardiovascular medicine. The detection of incidental coronary artery disease (CAD) in patients without functional myocardial ischemia is one example. ( 15) Despite the fact that atherosclerosis and its correlates, like coronary artery calcium, may be associated with an increased risk of cardiac events, knowing this information does not lead to management changes that improve patient outcomes. ( 16)

What causes a woman to be transferred from a nursing facility to the hospital with confusion and generalized weakness?

An older woman was transferred from a nursing facility to the hospital with confusion and generalized weakness. For such a patient, polypharmacy, infection, or worsening of her underlying dementia are the most likely causes. She was diagnosed with a urinary tract infection (UTI) on initial evaluation and started on antibiotics. A troponin, ordered as part of the initial evaluation, was found to be above the normal limit and cardiology was consulted.

What is the most common error in ordering diagnostic tests?

The ordering and interpretation of diagnostic tests in everyday medical decision making is seemingly simple, but riddled with error in actual practice. One of the most common errors that can lead to overtreatment is ordering diagnostic tests in patients with a low likelihood of the disease for which the test is being ordered. Such patients are more likely to have false positive than true positive results—even when highly specific tests, like troponin, are used. The pretest probability (i.e., likelihood) that a patient with confusion and weakness, without chest pain or dyspnea, with normal vital signs, and a nonischemic ECG is having an acute MI is essentially zero. Myocardial infarction is a clinical diagnosis—according to the Universal Definition, "the term acute myocardial infarction (MI) should be used when there is evidence of myocardial necrosis in a clinical setting consistent with acute myocardial ischaemia." ( 7)

Why are physicians not good at probabilistic reasoning?

( 10) Most physicians continue to provide effective and high-quality care by using heuristics. Remembering common illness scripts is a type of heuristic—for example, remembering the association between long flights and venous thromboembolism or that Lyme disease is associated with tick bites in New England. However, these simple shortcuts can lead to faulty reasoning or conclusions. ( 11) In particular, when illness scripts haven't caught up to newer diagnostic testing modalities, physicians tend to interpret the results too simplistically (e.g., elevated troponin = MI). Because of this, improving medical education , with an emphasis on developing probabilistic reasoning skills, is key to curbing overuse and its attendant consequences.

How many ED visits were there in 2009?

Turning specifically to the troponin, one study reported that of 44,448 ED visits in the United States in 2009 and 2010, troponin was tested in approximately 17% of the visits (representing 28.6 million visits).

Is UTI a clinical diagnosis?

Weakness and confusion in a patient with advanced dementia are highly nonspecific, and UTI, as a clinical diagnosis, requires symptoms. The patient did not present with any complaints of urinary symptoms or documentation of a fever, abdominal tenderness, or flank pain.

Is overuse common in medicine?

Overuse is common and physicians should be on the lookout for it in their practice.

How to report adverse events to the FDA?

Use one of the methods below to submit voluntary adverse event reports to the FDA: 1 Report Online 2 Consumer Reporting Form FDA 3500B. Follow the instructions on the form to either fax or mail it in for submission. For help filling out the form, see MedWatch Learn. 3 Call FDA at 1-800-FDA-1088 to report by telephone 4 Reporting Form FDA 3500 commonly used by health professionals. View Instructions for Form FDA 3500

What to do if you have a serious reaction to a medical product?

If you think you or someone in your family has experienced a serious reaction to a medical product, you are encouraged to take the reporting form to your doctor. Your health care provider can provide clinical information based on your medical record that can help FDA evaluate your report.

How to report FDA 3500B?

Consumer Reporting Form FDA 3500B. Follow the instructions on the form to either fax or mail it in for submission. For help filling out the form, see MedWatch Learn. Call FDA at 1-800-FDA-1088 to report by telephone. Reporting Form FDA 3500 commonly used by health professionals. View Instructions for Form FDA 3500.

How to contact the FDA about a product?

If you need information or if you have questions or comments about a medical product, please call the FDA's toll-free information line, 1-888-INFO-FDA (1-888-463-6332) Press 2 to report into MedWatch or for instructions.

How is overuse of medical services a problem?

Overuse, which is defined as the provision of medical services that are more likely to cause harm than good , is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.

What is underuse in healthcare?

• Underuse is responsible for substantial suffering, disability, and loss of life worldwide, in both high-income and low-income countries#N#• Underuse is prevalent across different types of health-care systems, payment models, and health services#N#• The causes of underuse are multi-layered:from inadequate access, health system failures, clinicians being unaware or unskilled to provide required interventions, and patients not accessing or declining them#N#• Underuse occurs alongside overuse, particularly in areas where there is competitive tension between profitable and low-cost interventions#N#• Policymakers, funders, clinicians, and civil society urgently need to recognise, invest, and resolve the slow uptake of effective, affordable, but non-promoted interventions

What are the factors that contribute to poor care?

We describe the network of influences that contribute to poor care and suggest that it is driven by factors that fall into three domains: money and finance; knowledge, bias, and uncertainty; and power and human relationships. In each domain the drivers operate at the global, national, regional, and individual level, and are modulated by the specific contexts within which they act. We discuss in detail drivers of poor care in each domain

What is universal health coverage?

Universal health coverage is a key step towards achieving the right care. Therefore, full consideration of potential levers of change must include an upstream perspective—ie, an understanding of the system-level factors that drive overuse and underuse, as well as the various incentives at work during a clinical encounter.

How can universal health coverage be deemed essential?

Each factor can be deemed as equally necessary but equally insufficient by itself. Reducing the role of greed by structuring financial incentives to maximise true clinical benefits and social value is key. Ensuring vigilance against error and bias, broadening research aims, and a focus on meaningful outcomes are key goals in the production of knowledge. Therefore, re-addressing imbalances of knowledge and power, not only within the clinician–patient relationship but also within delivery systems, and more broadly in society, is equally crucial. There are potentially many levers to remedy poor care, but evidence of effectiveness is very modest.

What is the history of health care?

The modern history of health care is littered with policy and practice inaction in the face of inappropriate care, often justified by an absence of evidence or uncertainty about what might result—Machiavelli’s “new order of things”. This lack of action should no longer be acceptable. Although the scale of the problem is vast and complex, a range of potentially effective remedies are available, with many more needed. Evidence-based medicine, HTA (health technology assessment), shared decision making, and countless other movements have surely nudged health systems to a point whereby we must ultimately acknowledge that a decision not to act is still a decision, and one with implications for people’s health. As efforts to improve the delivery of care continue worldwide, we must recognise that if the objective is to improve health, delivery systems need to be properly scaled and adapted to local needs and socioeconomic conditions to be maximally effective. Furthermore, delivery system leaders should remain humble about their systems’ contributions to health and should be unburdened from the task of substituting less effective medical spending for social spending. Transitions from the norm invariably cause conflict, but if efforts to achieve the right care are able to capture the full opportunity in front of us, the benefits to the wellbeing of patients, professionals, and the public as a whole are too great to condone inaction.

What is provision of care?

The provision of care is initiated by decision making within the doctor–patient relationship, but is substantially influenced by the resources available for health care within the society, its social and political contract, the state of global and local scientific knowledge, the configuration and capacity of the delivery system , and financing mechanisms.8,22,74,214 Achievement of the right care requires an understanding of and attentiveness to all these dimensions in the development of policy choices for promotion of care that is safe, effective, sensitive to personal preferences, and just.

How much is overuse of health care?

By some estimates, this kind of inefficient care represents up to 30 percent of all medical spending in the United States, amounting to $780 billion annually. At the same time, many cost-effective, highly beneficial services are chronically underused.

What is one contributing factor to overuse?

One of the papers included in the Lancet series notes that one contributing factor to overuse is that the scientific research agenda doesn’t match up well with our public health agenda. Why is that?

How many patients opt for a procedure after carefully weighing the pros and cons?

With certain exceptions, roughly 30 percent fewer patients will opt for a procedure after carefully weighing the pros and cons. That matches up with the 30 percent of uninformed patients who, after having certain procedures, say they regretted having it or would not recommend it to a friend. There’s enormous intrinsic value to engaging patients in their own care.

What percentage of treatment recommendations are based on strong evidence?

A recent review of guidelines from one major medical society found that only about 11 percent of treatment recommendations were based on what would be considered strong evidence, while 48 percent were based on weak evidence. Good guidelines really can make a difference.

Do poor countries have underuse problems?

It’s tempting to think that rich countries will have overuse problems and poor countries will have underuse problems, but it’s not that simple. In the U.S. and elsewhere, you actually see both—worthy, inexpensive interventions that are vastly underused and high-cost services of little or no value that are commonplace.

Is overuse and underuse a part of the conversation about health care?

Yes, absolutely. Overuse and underuse are now a central part of the conversation about fixing health care. Ten years ago, if you brought it up, people looked at you funny. Today, it’s widely acknowledged that the status quo isn’t cutting it any more.

Who is required to report abuse?

The laws in most states require helping professions in the front lines -- such as doctors and home health providers -- to report suspected abuse or neglect. These professionals are called mandated reporters. Under the laws of eight states, "any person" is required to report a suspicion of mistreatment.

What to do if you suspect abuse?

If the danger is not immediate, but you suspect that abuse has occurred or is occurring, please tell someone. Relay your concerns to the local adult protective services, long-term care ombudsman, or the police.

How to contact Eldercare Locator?

Please tell your doctor, a friend, or a family member you trust, or call the Eldercare Locator help line immediately. You can reach the Eldercare Locator by telephone at 1-800-677-1116. Specially trained operators will refer you to a local agency that can help. The Eldercare Locator is open Monday through Friday, 9 ...

Why is the ER so expensive?

Emergency Room overuse is a big problem for all of us for several reasons: The costs are much higher than for other care environments.

What does EDIE stand for in emergency room?

In 2013 the Washington State Hospital Association launched a technology program called EDIE, which stands for Emergency Department Information Exchange.

Can a urinary tract infection be handled in the same unit as an auto accident?

Typically sprains and strains, upper respiratory infections, and urinary tract infections should not be handled by the same unit that cares for auto accidents and gunshot wounds. There was one patient who had used the ER over 300 times in one year for those kinds of issues.

How to find out what other patients have to say about their recent hospital stays?

To find out what other patients had to say about their recent hospital stays, visit the Hospital Compare Web site. You'll find answers from patients about how well doctors and nurses communicated, how well patients' pain was controlled, and how patients rated their hospital.

How to complain about poor care in a hospital?

How can I complain about poor medical care I received in a hospital? While you are in the hospital: If possible, first bring your complaints to your doctor and nurses. Be as specific as you can and ask how your complaint can be resolved. You can also ask to speak to a hospital social worker who can help solve problems and identify resources.

What to do if you are discharged before you're ready?

If you are discharged before you're ready: This is a big concern for many patients because insurers balk at long hospital stay s. Talk to the hospital discharge planner (often a social worker) if you don't think you're medically ready to leave the hospital. The discharge planner will take your concerns to the doctor who makes this decision.

What do social workers do when patients leave the hospital?

Social workers also organize services and paperwork when patients leave the hospital. If you are covered by Medicare, you can file a complaint about your care with your State's Quality Improvement Organization (QIO) . These groups act on behalf of Medicare to address complaints about care provided to people covered by Medicare.

What do you do if you get an infection in the hospital?

If you get an infection while you are in the hospital or have problems getting the right medication, you can file a complaint with the Joint Commission . This group certifies many U.S. hospitals' safety and security practices and looks into complaints about patients' rights. It does not oversee medical care or how the hospital may bill you.

Is it easy to be assertive in a health care setting?

Even with this information, it's not easy to be as assertive in a health care setting as it is in an auto repair shop or restaurant. But it's a smart move that can help you get the quality care that you deserve.

Can a hospital discharge you until appeal is completed?

The hospital cannot discharge you until the appeal is completed. When you get your hospital bill: First, ask your doctor or the hospital's billing department to explain the charges. Find out how the hospital handles complaints about bills, and make your case. If you still have questions, you should contact the Medicare carrier ...

Case Objectives

See more on psnet.ahrq.gov

The Case

The Commentary

Take-Home Points

References