Is starting an unnecessary IV fraud?

[ExpatMedic0]

Here is one for you all. I don't know about you, but I have seen a lot of BS prehospital IV's started in my time for no reason. I once asked a provider why he started IV's on every transport and he replied "because we can."
Not only does this open the patient up to a higher risk of infections and complications, but its a costly unnecessary procedure. Furthermore, if there is no medical necessity for the IV, depending on your billing system, it could effect the patients ambulance bill or the insurance payment, which I consider fraud.

Any thoughts?

 

[CriticalCareIFT]

One needs to perform the skill to maintain adequate proficiency for the select few patients who really do require IV access. If you only initiate IV access on very small percentage of patients who truly need it, you may lose the dexterity and precision and the diabetic with BGL of 30mg/dl who is laying on the floor with non perfect vasculature, would be a tough stick or you may not even get access if you seldom perform the procedure.

Peripheral IV access is not central canulation and does not carry such stringent criteria and believe it or not, even central access gets places on patients who do not always need it, because residents need practice and attendings need skill maintenance.

Fact: majority of ALS calls are really BLS, or they can even take the cab. That 10-15% would constitute an ALS call, if we only performed IV access on 10-15% of the time, how would you maintain proficiency? IV access will turn into intubation as we experience it now.

 

[medicsb]

I have heard of at least one instance of a service getting audited and having to justify why certain patients were transported ALS, and many of the transports questioned were ones where only an IV was placed. I expect this will happen more frequently.

In my experience, medics in "all-ALS" systems are somehow compelled to treat everyone with VOMIT (y'know: vitals, O2, monitor, IV, transport), when vitals and transport are all that is needed. I imagine at some point an IV and monitor will no longer be considered an ALS intervention and will not generate a higher billing rate.

 

[Medic Tim]

Never really thought about it as we don't have itemized bills. ALS or BLS it doesn't matter. Same flat fee.

I only do IVs on pts I am going to give fluid or meds to. It is common for me to not start one "because the protocol" sad to. This has cut down on my number of IVs but I am still able to do enough to stay proficient.

 

[medicsb]

Never really thought about it as we don't have itemized bills. ALS or BLS it doesn't matter. Same flat fee.

I only do IVs on pts I am going to give fluid or meds to. It is common for me to not start one "because the protocol" sad to. This has cut down on my number of IVs but I am still able to do enough to stay proficient.

I'm not an expert on billing by any means. But in the US there is no itemized billing (though there may be exceptions), but there are pre-defined billing levels based on what was done for the patient. I believe the it's BLS non-emergency, BLS emergency, ALS-1, ALS-2, and SCT. And then the service can charge a per-mile rate. Difference between ALS-1 and 2 is the number of meds administered (≥3 for ALS-2 and IV solution and O2 do not count) and certain procedures (intubation, cardioversion, pacing, etc.).

I did once hear of a service purposely not stocking duoneb, so that they could bill ALS-2 on most COPD and asthma patients, because if they gave the atrovent separately from the albuterol that was 2 meds whereas giving a "duoneb" counted as one med (the third med for the ALS-2 would be solu-medrol).

 

[Ewok Jerky]

Here is one for you all. I don't know about you, but I have seen a lot of BS prehospital IV's started in my time for no reason. I once asked a provider why he started IV's on every transport and he replied "because we can."
Not only does this open the patient up to a higher risk of infections and complications, but its a costly unnecessary procedure. Furthermore, if there is no medical necessity for the IV, depending on your billing system, it could effect the patients ambulance bill or the insurance payment, which I consider fraud.

Any thoughts?

I dont think "because we can" cuts it...but certainly "because I might need it later" can fly given a rational line of thought from presentation and Hx to possible outcomes.

 

[Bullets]

One needs to perform the skill to maintain adequate proficiency for the select few patients who really do require IV access. If you only initiate IV access on very small percentage of patients who truly need it, you may lose the dexterity and precision and the diabetic with BGL of 30mg/dl who is laying on the floor with non perfect vasculature, would be a tough stick or you may not even get access if you seldom perform the procedure.

Peripheral IV access is not central canulation and does not carry such stringent criteria and believe it or not, even central access gets places on patients who do not always need it, because residents need practice and attendings need skill maintenance.

Fact: majority of ALS calls are really BLS, or they can even take the cab. That 10-15% would constitute an ALS call, if we only performed IV access on 10-15% of the time, how would you maintain proficiency? IV access will turn into intubation as we experience it now.

I dont insert pharyngeal airways every day, but based on your reasoning, everyone is getting a NPA now.

Patient doesnt NEED an NPA, but i need to practice the skill of measuring a correct size.

 

[Carlos Danger]

Here is one for you all. I don't know about you, but I have seen a lot of BS prehospital IV's started in my time for no reason. I once asked a provider why he started IV's on every transport and he replied "because we can."
Not only does this open the patient up to a higher risk of infections and complications, but its a costly unnecessary procedure. Furthermore, if there is no medical necessity for the IV, depending on your billing system, it could effect the patients ambulance bill or the insurance payment, which I consider fraud.

That is an excellent point and question.

The last 911 ground job I had, I was frequently scolded for not starting IV's or doing 12-leads. My philosophy was, if I don't plan to give meds or fluids, the patient doesn't need an IV from me. And for that reason, I rarely started them even though many other paramedics would start them on almost everyone.

Of course, the only reason the company cared was because they could bill at the higher ALS rate if the patient had an IV.

One needs to perform the skill to maintain adequate proficiency for the select few patients who really do require IV access. If you only initiate IV access on very small percentage of patients who truly need it, you may lose the dexterity and precision and the diabetic with BGL of 30mg/dl who is laying on the floor with non perfect vasculature, would be a tough stick or you may not even get access if you seldom perform the procedure.

"We need to practice" is an extremely poor justification for exposing a patient to unnecessary costs and risk.

 

[AeroClinician]

If the pt. is going to / possibly have blood drawn for labs at the hospital during their course of care. How is vascular access prior to arrival, fraud? It's for an actual purpose. Prehospital vascular access allows blood to be drawn faster.

Now I know what some are going to say, " they don't use our line becaus it's a "field line" ". I call BS, I couldn't tell you how many times I see RNs draw blood out of my line upon arrival after aspirating a good 10cc of blood first.

A sizable portion of ALS pt.s have the potential to deteriorate, wouldn't you like to have a line already in place if that happens?

 

[VFlutter]

If the pt. is going to / possibly have blood drawn for labs at the hospital during their course of care. How is vascular access prior to arrival, fraud? It's for an actual purpose. Prehospital vascular access allows blood to be drawn faster.

Now I know what some are going to say, " they don't use our line becaus it's a "field line" ". I call BS, I couldn't tell you how many times I see RNs draw blood out of my line upon arrival after aspirating a good 10cc of blood first.

It may happen but it is poor practice. We do not draw labs off peripheral IVs. If we absolutely can't get labs we will do an arterial stick.

I will try to find some studies but I know our hospitals informal evaluation showed that the majority of hemolyzed and rejected lab draws came from the ER where it was standard practice to draw off PIVs.

 

[ExpatMedic0]

That is an excellent point and question.

The last 911 ground job I had, I was frequently scolded for not starting IV's or doing 12-leads. My philosophy was, if I don't plan to give meds or fluids, the patient doesn't need an IV from me. And for that reason, I rarely started them even though many other paramedics would start them on almost everyone.

Of course, the only reason the company cared was because they could bill at the higher ALS rate if the patient had an IV.



"We need to practice" is an extremely poor justification for exposing a patient to unnecessary costs and risk.

I just learned this, but check this out
http://quitam-lawyer.com/ambulance-fraud.html

Whistle blower rewards are now offered for providers reporting possible fraud. I believe that probably includes being forced to do an "ALS" procedure that is medically unnecessary just for billing purposes.

 

[Summit]

In answer to OP's question, fraud if unjustifiably unnecessary invasive procedures are billed for period. If providers are providing invasive procedures without reason, that is unprofessional, unethical, and grounds for reprimand or referral to their certifying board's review panel.

One needs to perform the skill to maintain adequate proficiency for the select few patients who really do require IV access. If you only initiate IV access on very small percentage of patients who truly need it, you may lose the dexterity and precision and the diabetic with BGL of 30mg/dl who is laying on the floor with non perfect vasculature, would be a tough stick or you may not even get access if you seldom perform the procedure.

Peripheral IV access is not central canulation and does not carry such stringent criteria and believe it or not, even central access gets places on patients who do not always need it, because residents need practice and attendings need skill maintenance.

Fact: majority of ALS calls are really BLS, or they can even take the cab. That 10-15% would constitute an ALS call, if we only performed IV access on 10-15% of the time, how would you maintain proficiency? IV access will turn into intubation as we experience it now.

I would never perform an unwarranted invasive procedure on a patient because "I need the practice for the people who really need it." That is an outrageously unethical attitude. If that lack of professionalism is rampant in your system, you should be the agent of change. I certainly hope you don't buy into that horsehockey.

I find most of that post entirely ludicrous in both claim and reasoning.

 

[VFlutter]

even central access gets places on patients who do not always need it, because residents need practice and attendings need skill maintenance.

I find most of that post entirely ludicrous in both claim and reasoning.

You mean your Intensivist doesn't float Swans on patients, who do not need one, for practice? He must be rusty.

 

[truetiger]

I noticed some of you only start IV's when YOU plan to use them, but what about our hospitals? What percentage of ER patient's get an IV? I'll start an IV on anyone I suspect would get one in the ER. Our ER's are busy and they truly appreciate anything we can do to cut down on their to do list when we arrive. I cringe when I hear providers say that "oh they'll do that when they get to the hospital" or "I was too close to the hospital to perform xxx intervention...) I think its best practice to treat your patient's just as the hospital would, protocols allowing.

 

[teedubbyaw]

Starting then for practice is silly, and starting them because they'll get one in the hospital is NOT a reason to do it.

 

[Summit]

Know your receiving facility. Many EDs will pull every field line as "dirty" unless its critical, and restart it if needed. If that is not the case, and they need one for the ED, sure!

 

[Tigger]

Practicing IV skills on patients that do not need them is not in any way a justifiable reason to start one, especially if it costs the patient more money. That's downright deplorable.

Most patients I take to our in town Level 4 ED get an IV, but that is at staff request. There's only 1-2 RNs and a tech, so "busy" for them is like three patients. In Colorado IVs can be billed as BLS, so the bill doesn't go up at least.

Otherwise, it needs to be medically indicated, and not be a "I had time so I did it" type thing. I also don't want to have the patient get stuck more time than needed or ruin a perfectly good site for the hospital to draw labs off of.

Sure I can get a 22 in an elderly man's hand, but when we get downtown 45 minutes later, I doubt they'll be able to draw off of it and that might have been the best site available. Now I've made more work for everyone.

 

[Akulahawk]

If my patient needs vascular access because I suspect that I will have to administer medication, I'll start the line. Whether it's a line or a lock depends upon whether my patient needs fluids and if I have the right tubing to do it. My view is that if I'm starting a line on a patient, I have to be able to justify it and "the hospital will start one" won't fly.

 

[CriticalCareIFT]

Please get of your high horses about this noble pursuit of "only if truly required". If you followed this rule you would be performing maybe 1 IV a day or most likely not at all, as majority of ALS calls don't "truly require" IV access. I guess none saw any flaw with this statement "because I might need it later" which translates to we starting one either way, wether you need it now or not.

And unless you got multi-venous IV training arm at home or at your station there is no way you initiating IV access often enough to maintain adequate proficiency on the poor vasculature patients.

This is not the ER where I see 8+ patients and most will require specimen collections where you will practice your skill.

And what is your response when the patient truly requires IV access and you are unable to obtain it due to skill degradation? So you will stab him multiple times and then transport to the ED telling you battle story "It such a hard stick you know, very hard!".

I guess none of you saw residents place central lines during cardiac arrest, because certainly main reason they doing it is out of patient necessity.

This is a chief reason intubation is highly contested, we don't do it nearly enough, and very few go to the operating theater for practice. Now before some of you hit your keys with furious anger, I do not advocate intubating everyone you come across. However peripheral IV access does not carry the same deleterious effects when appropriately conducted yet crucial for certain calls.

 

[ffemt8978]