COMMENTS FROM PHYSICIANS REGARDING AMA/HCFA "E&M DOCUMENTATION GUIDELINES"

Sent to the Association of American Physicians and Surgeons 1601 N. Tucson Blvd. Suite 9, Tucson, AZ 85716, (800)635-1196

>Pointless, insulting, offensive, silly, harassment, to be contested

>Stupid (x2)

>Complete waste of time and effort. Does not add to patients' care.

>A "sell out" of its own members by organized medicine.

>Compliance is impossible, "medically necessary" is impossible.

>Will not improve care, will increase paperwork and will be used to intimidate physicians

>Abusive, intrusive, outrageous, impossible to adhere to

>Unnecessary and burdensome

>Absolutely ridiculous!

>An incredible waste of time

>Burdensome, time wasteful and not any guarantee against fraud since any doctor can still falsify the record.

>Intrusive and counter-productive in practicing good patient care, especially in my field of psychiatry

>Crazy

>Too difficult to follow

>A way to standardize documentation

>Cumbersome, unnecessary, pain in the neck

>Unlawful unless they are just guidelines

>Cumbersome and problematic

>Cumbersome, not medical care based

>First step in tyranny

>Unreasonable requirement, to make physicians felons to save money for Medicare

>Words do lie and liars can write

>A political tool to destroy private practice

>Ban them

>Cumbersome, excessive, of no known benefit to patient care, no studies to support their use

>Cumbersome, destructive, unusable

>Ridiculous

>Absurd

>Impossible to comply with

>An invasion of privacy

>Don't really know the legality

>Dangerous and ill considered

>Another way to regiment physicians and bring them under political control

>Pain in the *** (x2)

>Laborious and unnecessary

>Destructive of natural medical thought processes

>A violation of physician patient confidentiality and inappropriate

>Just unnecessary (x3)

>An intrusion

>Terrible waste of time, confusing, complicated

>Inappropriate means of stressing importance of good documentation

>Not practical

>An onerous unnecessary burden, cumbersome,..., difficult to read

>Ridiculous

>An intrusion and unneeded burden

>An absolute outrage - all physicians should leave Medicare

>Too complicated

>Waste of doctors' time and money

>OK in concept to fight fraud but unnecessarily burdensome, unclear, not medically sound

>Stupid, cowardly, and wrong

>We need to get back to the patient being responsible for the bill, not the government

>Punishment of MDs

>Arbitrary and capricious

>A logical extension of the police state

>Illegal rules

>Hurts the patients and practice of medicine

>A pain

>Busy work - takes away from time to talk and listen to patients

>A violation of patient privacy

>Will increase costs and decrease doctor availability

>Insulting and demoralizing

>Ridiculous

>Insulting - 1st year med student [exercise]

>Tyranny

>Terrible abuse of government power

>A process by which the federal government attempts to gain control over medicine

>Counterproductive and detracts form appropriate medical care while also distorting that care

>Burdensome and intrusive

>Unnecessarily intrusive, astonishingly time consuming, meant to chill higher code activity.

>Justifying the jobs of bureaucrats and head hunters.

>Impossible to enforce fairly

>Part of a systematic breakdown of the physician-patient relationship

>A means to criminalize at will members of a profession

>Unethical and immoral

>Irrelevant

>Morally decrepit and offensive

>One reason I quit AMA

>A waste of time

>An invitation to cheaters

>Unworkable

>Increases my paperwork documentation time by about 25%, and I can charge nothing [for it]!

>Not understandable

>Of no value in patient care

>One more government mandate that does nothing for patient care.

>A way for bureaucrats to interfere with patient privacy

>A means to limit physician payments

>A way to game the coding system

>Interferes with good medical care

>Is a communistic approach

>Discriminatory and degrading to my standards

>Road to serfdom

>Wasteful, dangerous, unnecessary

>Totally unreasonable

>Time-wasting intrusion in the process of care giving

>Guidelines - but not mandatory, can be used if we desire.

>Meddlesome, oppressive and unrealistic

>Harmful to patients and restricts their access to care

>A clinical entrapment technique to recoup (recycle) Medicare funds

>Unreasonable

>Ridiculous and will force me out of Medicare

>Another attempt to destroy legitimate medicine so the government dictate can be established. Do keep trying to stem the tide.

>Stupid/pointless

>Onerous and divisive

>Burdensome and may not improve care

>The reason I already belong to AAPS

>The best defense I have for reimbursement and liability.

>Intrusive - just another way to make us work for free!

>Extra trouble and only serves the inspectors not the patients

>Another example of how useless the AMA is

>Are too burdensome

>An outrageous demand on physicians time

>As bad for physicians as the term "kulak" was for Russian peasants.

>A method of entrapment as it is so complicated mistakes cannot be avoided, and mistakes are now fraud and abuse

>No big deal - actually helps to upcode

>Useless burden and tool to control patient and doctor

>Unreasonable and cumbersome, will cause downcoding

>Another step towards socialized medicine

>Burdensome and detracts from efficient patient care

>Excessive and discriminatory

>A vain attempt to painstakingly ascertain a physician's mental work product

>Intrusive

>Demeaning, doctors are coerced to follow vague, complex rules

>Too complex, impossible to do correctly and have time to work

>Extreme waste of MD time and money

>Really really stupid

>Another bureaucratic hassle factor

>The kiss of death for our profession

>Ridiculous, but a tool needed by HCFA payors

>A detriment to good medical care

>Absurd, unreasonable, punitive

>A waste of time and counterproductive

>A reason not to join the AMA

>Detrimental to quality patient care

>Totally unrelated to the art and science of practicing medicine

>Part of socialistic Medicare program - a natural progression

>No true measure of service or competence

>Satisfies only "clipboard cadets"

>Incredible governmental intrusion into the practice of medicine

>Don't know constitutional issues, but I don't want more regulation

>Indicates that the AMA is truly a fascist organization. DO NOT QUOTE ME

>A way to encourage many of us baby boomers to retire from medicine altogether. Too much risk.

>Should be less detailed and should not be used punitively

>An unfunded mandate for me to spend all my free time doing medical student write-ups of no benefit to the patients

>May be lawful but detracts from patient care

>Too cumbersome

>A tool to deny coverage and avoid payments

>Another boost for the "compliance" industry/ seminars/ consultants/ etc.

>Boneheaded, stupid, evil, asinine, idiotic

>Burdensome and will increase charge per visit

>Deliberately made too complicated

>Dangerous for society

>After 20+ years of practice, I don't need "our" government's input regarding documentation.

>Outrageous

>Pain, inappropriate

>Amount to a method of entrapment

>Potential source to harass physicians

>A reason to quit the AMA

>Excessive and lacking in common sense

>Maybe unlawful - unsure

>Freshman med school exercise

>Impossible to comply with

>A form of harassment to make us downcode

>Needless bureaucratic paperwork

>Stupid, confusing

>Takes time away from the direct patient - physician information and counseling time.

>Obviously necessary to control wages and prices

>Your organization is what the AMA should be about and I have written them in reference that. The article on Jane Orient in Forbes is excellent.

>Spend more time on paperwork than on patient treatment

>The government's tactics are too heavy handed. The code is too complicated to be practical. It should be revised and simplified.

>Instead of learning how to take care of patients I spent a whole Saturday morning learning how to avoid fraud and abuse allegations in my practice! This is not why I became a doctor!

>I agree with the five points you have brought up.

>A backlash by MDs will occur without question.

>The government, as always, is simplicity challenged and I think HCFA is very hostile toward M.D.s. HCFA must be aggressively opposed.

>I don't know enough.

>I just received an audit from Medicare.

>I am totally against the E and M guidelines, and the AMA should be ashamed for their share of it.

>In emergency medicine with the critical nature of the problems, language barriers, lack of educational level of many patients, the history cannot be done in all cases.

>Since I have not seen the guidelines, I cannot remark at this time.

>My personal documentation exceeds that required in most cases. I disagree with government dictating such things, while not allowing doctors to set and maintain standards.

>We think we will see fewer Medicare patient visits, document all the bullets and charge more for higher "level of service." The actual patient care will be the same, just spread out more - cost more.

>Definitely we should challenge this.

>I have no money. I'm going to try to scrape $275 together to join. I work 90-100 hrs. per week. Make 100,000+, have bills up the gazoo.

>These tedious and time-consuming guidelines could easily bankrupt most family practices.

>I would like to send you a contribution, however I was terminated from Aetna US Healthcare last year for not scoring high enough based on E&M documentation. This has cost me $5000 in legal fees and $6000 a month for 8 months in capitation payments.

>Check on our costs. Those that are stealing are obvious. Attack them and let the rest of us practice medicine.

>It's about time [to challenge them]

>Sorry unable to donate money now but more power to you (disabled)

>I have taken a prolonged "sabbatical" because of this terrible intrusion on my practice by the government - ever since Medicare. Politicians who only saw medicine as a cheap "good" that could be given to the citizens for the politicians' gain, stepped into medicine without understanding all the free care we were delivering and the very careful manner in which MDs and specialists traded their service back and forth. They tried to disassemble a Swiss watch and will rue the day.

>Go get 'em! (x3)

>I am in my first year of practice and already want to retire because of the hassles involved in documentation. I will not stay in medicine long if this lasts.

>Bureaucratic b.s.!

>I oppose overall such regulation.

>These guidelines are really an excuse not to pay for provided services!

>These encroachments will continue as long as the government continues its adherence to the monetary provisions of the Articles of Confederation, which were revoked in 1798.

>Unfair burden

>I think the guidelines themselves are ok. It is the loss of due process and patient rights that I am concerned about.

>Laws for docs - How about some regulations for regulators!

>Cannot afford dues but am concerned about erosion of practice of medicine.

>It is ridiculous to just judge from records and not the end results of given medical care to the patients. It just adds paper mess and cost to operate our business.

>Guidelines are definitely too cumbersome and obtuse. Will be impossible to comply with.

>Good Luck (x2)

>I am not opposed to educating providers to document well, but not at the patient's expense.

>I have withdrawn my AMA membership.

>If the guidelines were realistic they would be ok, but everyone practices differently and documents differently.

>Go for it. (x3)

>The public has little knowledge of what the government is doing to Medicare.

>The AMA does not represent the private physicians. The AMA is an embarrassment to the profession and people of the USA.

>I am retired but a strong supporter of AAPS. I hope this small contribution will help.

>I am glad someone is resisting the encroachment of more control and intrusion with patient care.

>Thank you (x3)

>Government is forcing all physicians to commit fraud and deception and to become criminals.

>Virtually impossible to comply with, virtually irrelevant to quality of care and set up for selective enforcement

>I think E and M guidelines are a way to "catch" us, no matter what we do. We must stop our out of control government. In one of my speeches I compared it to abuse. They can only abuse us if we let them. (AAPS quoted me.) I hope there are enough members to lead the rebellion someday.

>I can either practice medicine or comply with the documentation guidelines.

>Keep up the good work. Hold the faith of freedom and self determination. You will suffer "the slings and arrows" but continue to take up arms!!!

>An intrusion into patient's privacy is important consideration in this legislation.

>E/M was the last straw. I have "opted-out" of medicare with a loss of only 4 of 212 patients. I encourage everyone to do so. The sense of freedom is wonderful. DO NOT USE NAME IF QUOTED

>Most MDs see/file > 100 Medicare claims in any 2-week period. Even if we are in compliance 99% of the time, with the ability to fine MDs $10,000/event, HCFA can selectively shut down any physician they want, as 100 claims/2wk = $250,000 in fines per year under best of circumstances. One cannot reduce a quality office visit to a series of check boxes.

>I don't know what they are.

>These "guidelines" are a farce designed to make sure that anyone who is audited is not in compliance.

>AMA has no authority to represent me.

>Just one more regulation to deal with.

>I have patients who stormed out because they felt I invaded their privacy.

>The government bureaucrats and lawyers need to criminalize physicians so that they can be seen as the saviors and protectors of "the people." I can remember a time when the physicians and clergy were the pillars of a community, and respected as such. We must resist for the good of the country and the love of the constitution.

>Thank you, Jane, and thank you AAPS, for once again being the advocate for patients and physicians.

>If they are instituted, I will stop seeing all Medicare patients in my practice after 16 years of accumulating Medicare patients.

>These requirements absolutely infuriated me. It is none of anybody else's business except for the patient to justify what labs I order. This must be stopped. Go get em! Bravo. I am delighted someone is tackling this as I was exceptionally upset at this. Good work!

>What a ridiculing waste of time.

>Something is necessary and appropriate to combat fraud. How to do it without being heavy handed and unfair to innocent physicians - the greedy among us set the stage (provided an excuse) for governments proclivity to intrude, control, and take over. I haven't seen the guidelines but I probably disapprove based on Medicare's unreasonableness in dealing with me where they took back [payments] for services I'd rendered.

>Your brilliant activities and strategic plans continue to amaze and encourage me.

>Thank you. Stop the E and M documentation guidelines.

>I have tried to simplify the proposed E and M Guidelines in my orthopedic approach to patients and I literally cannot understand the guidelines.

>The guidelines represent an onerous burdensome intrusion into the practice of providing cost-efficient relevant, good health care to our patients.

>These "guidelines" are just an attempt to shift the blame for waste and poor fiscal management from the government to the doctor.

>Once again the AMA has shown that it is not genuinely working for physicians' best interests.

>The neurology guidelines are stupid. I have to spend time concentrating on the neuro exam. They are requiring a cardiovascular exam which will waste time when not needed. They can't tell me how to do an exam after I've been trained and board certified. I've been practicing for 13 yrs. My specialty organization has sold me out. Same as the AMA.

>Clear evidence that the AMA is not the physicians advocate. Acceptance of "bullet-counting" will only result in a self-inflicted death.

>Even more than demeaning, if I do an H and P as an interventionalist I cannot even submit an E and M charge. If I don't do and H and P, I feel it's malpractice - so I do it anyway. As a hospital based physician the AMA has long since ceased to represent me.

>The AMA is America's version of Vichy collaborators who sell out the cause of freedom and liberty to curry favor with tyranny.

>I think E and M guidelines are setting doctors up for severe audits. Look out!!

>The government needs to get out of the health care business.

>The E and M guidelines are simply a ploy to facilitate audits and recovery of funds for HCFA. They have nothing to do with quality of care - in fact time devoted to them is time not given to patient care.

>Guidelines might be ok only as educational tools.

>Keep up the good work! I'm contributing this year while I can still afford it.

>If we could go back in time 60 years we might be in Berlin, or Orwell's 1984.

>Go to it! HCFA may have the instincts of the KGB or Hitler's SS elite.

>Keep up the good work (x3).

>Guidelines are part of a scheme to plunder assets of physicians for the past work they have been paid for. Should be a cautionary talk for prospective medical students!

>It's about time someone filed suit.

>Agree fully.

>Let'em have it! My anger and depression after attending a E and M conference last week, has been transformed to hope with your message to fight.

>ACEP has significant disagreements with the new E and M guidelines!!

>I have ceased to see Medicare patients as of 1/1/98.

>A reason to quit the AMA. A plague on them.

>Exerts increased control that is unnecessary.

>There is no such thing as conscience in America today. Nobody listens until the Judge makes them listen; that is the Clinton legacy.

>I can't afford at this time to join.

>Don't let them tread on us! Fight on! Another curious (and no surprise) item: The documentation produced by HMOs in Medicare is not anywhere near meeting criteria. Corporate doctors are held to different standards than solo private doctors. Ever see office notes for Kaiser?

>More bureaucratic red tape and more ammunition for fraud, etc.

>Let physicians and patients have the right to decide medical decisions without "big brother" sticking his nose in the process.

>Sic 'em!

>There is fraud in the health care industry which we must also be willing to confront if doctors are to maintain their credibility. If we don't assume this responsibility, then documentation guidelines will be our fault.

>One more reason to divorce myself from Medicare, HCFA, and intrusive policy wonks.

>The AMA has sold us out for years. We need to defend our profession. For the first time in 18 years will not be a member of either my state or county medical society. Try to enlist the support of ASIM. They have strong support within the Senate and Congress.

>It's not unusual to spend more time to observe and adhere to rules that detract from one's ability to concentrate and expend energy on patient care. At times the whole of medicine seems impossible when one tries to care for patients.

>If the federal government prosecutes in civil rather than criminal court, does this de facto violate a citizen's rights since civil cases give less protection to the accused than criminal cases?

>Why are they called guidelines? They are laws.

>Nail them to the wall.

>About time someone does something about this nonsense.

>Give them hell. If we must go down - let us go down fighting!!!

>You aren't going to win this one - why try. Use resources elsewhere, but keep up the overall good work.

>You are exactly right: compliance is impossible! No doctor or group could withstand an audit.

>Sue AMA and HCFA for violating anti-trust laws. Most physicians had no input into designing E and M guidelines.

>Would like copy of guidelines.

>Continue recruitment efforts

>Am trying to recruit my hospital staff to join AAPS for support. This may be the straw that breaks the camel's back. >Overbearing intrusion of the government on the delivery of care can ruin this country.

>If the goal is to improve records and follow outcomes, voluntary participation through our various specialty organizations is a better way and can preserve privacy.

>Where's the AMA?

>I suggest civil disobedience! Nobody should do this or pay any attention to any regulations promulgated by HCFA.

>Go for it! Preemptive court challenge is the only way to stop implementation.

>I suggest a mass appeal to publicize new, helpful procedures - ...and not submit them for codification.

>My documentation of patient encounters exceeds the guidelines. However, good medical care is not necessarily tied into extent of documentation. I believe it is unlawful and unconstitutional to require the guidelines. Medicine is an art as well as a science and the art cannot always be documented. Good documentation does not necessarily equal good medicine.

>I'm disgusted with the proliferation of paperwork. Each year I spend more time in the "paper" hospital and less on patient care. There are too many bureaucrats making too many rules. In trying to create "the perfect" not only have they got in the way of "the good", they have created a nightmare. William Shakespeare was right, "striving to be better, oft we mar what's well."

>Please send a letter to our county medical society and encourage them to support and join the lawsuit.

>I wish [the lawsuit] wasn't necessary

>Main concern is patient confidentiality and imposition of additional paperwork that does not have relationship to quality of care.

>Medical totalitarianism looms on the horizon, and unless we stand against it despotism will triumph and the meaningful exercises of medical judgement, which requires independence, will vanish.

>No more Medicare, and if these rules are applied to the private sector, no more medicine.

>Thanks for fighting back! Please send me a form for a donation to the American Legal Health Foundation.

>Please do all you can to fight these ridiculous government regulations - which have no impact on patients' health and detract from patient care.

>In any generation liberty is defended by only a few. Yours is an eloquent voice among them. If enough respond, perhaps the outcome will be better than a heroic defeat.

>How many guesses do I get? You're the only hope I have to be able to pay my dues one more time.

>Unfortunately, MDs have always been "nice boys and girls" who do what we are told. It's time to change.

>Every physician I know is in fear of fines or imprisonment. We fear we are doomed to condemnation.

>Give 'em hell

>Against the government in general for interfering in doctor-patient relationship

>Too much gov't, too many hours, too little pay

>In theory they are good guidelines but should never initiate clinical proceedings or fines.

>The proposed EM guidelines are indeed impossible to meet. I agree with you on that. It will no longer be possible for physicians to bill for 4 or 5 comprehensive visits in an hour and get away with it. That is both good and bad. If the EM guidelines are applied and enforced then the game will be over and the resulting financial crunch will have physicians in rebellion. That is good.

>Please study the case of ASD v. Shalala in which the DC court of appeals failed to address the FACA issue which was the basis of the suit. As far as I'm concerned, the FACA issue is as valid as ever and AAPS should avail itself of any and everything which might help.

>The costs of enforcing the guidelines (building, bureaucrats, and agents - i.e. stormtroopers) are paid for by the fines against hospitals and physicians - this is Nazism.

>Guidelines/documentation issues were used against physicians by government administrators of health system in $30 million settlement at Univ. of PA.

>I would demand that pilot studies be conducted to determine the increased amount of time per patient that compliance with these guidelines requires and that compensation per patient be increased for this.

>This is the greatest threat to the practice of medicine yet launched by HCFA.

>Bravo to AAPS for taking a stand on this issue.

>Go get the bastards.

>I will continue to support AHLF in their struggle with this evil.

>Go for it! Can I help?

>They are a tool to make it easier for nonmedical reviewers to deny payment and target physicians for fraud and abuse.

>Include the AMA among the organizations you sue.

>Nothing but further intrusion of government into affairs of private citizens.

>Please keep up the fight against socialism and government control.

>Hang in there.

>Thanks for fighting this atrocity.

>E and M guidelines have been deliberately made too complicated as part of the "criminalization" of medicine.

>The AMA and AHA sold us down the bureaucratic path. I was a small hospital administrator for 28 years. Am in sympathy with your views. We goofed when we let Medicare in. I was a good friend of Dr. Jaggard.

>I am afraid the government will create another IRS with unlimited powers and gross opportunities for abuse in the name of diligence.

>"Confusion now hath made his masterpiece." Shakespeare - Macbeth II.2.65. The above could be applied to many of the statist guidelines that rule us.

>More power to you!

>Go for it. EM codes are bad medicine.

>This is just another effort to give physicians a good reason to limit their Medicare "participation." Then government can force us to "accept" their "terms" as a condition for licensure.

>Physicians will be focusing on documentation and avoidance of fraud and abuse in deterrence to good and focused patient care. The efforts would be better directed towards journalists and attorneys.

>The guidelines are insane. What's next? Stormtroopers. A Ray Bradbury Fahrenheit 451 scenario. Go for the jugular.

>I know the AMA is trying to revise the guidelines. Obviously, my biggest concern is despite good patient care and appropriate treatment, you can still be a criminal if the paperwork is not done.

>I find these strict requirements burdensome. My evals are usually excellent.

>We must join efforts all across the land to reduce the influence of the federal government on the private practice of medicine.

>I withdrew from Medicare participation 1/1/98.

>Get government out of medicine.

>If necessary to achieve a workable system without increasing our paperwork burden which means more time for ever decreasing pay.

>Absent any guidelines, how do you propose to account/audit physician billings?

>The documentation requirements do not guarantee or even promote good medical care. They promote obsession with nonessential details to avoid fraud charges.

>A very complex system. That is difficult to do. They are asking for 100% compliance of a system about as complex as the tax law.

>Undermines my ability to care for my patient, takes excessive time, casts shadow of guilt on physician, destroys patient-doctor relationship, too much bureaucracy, tax burden excessive

>E and M codes do not allow one to incorporate level of training and experience into them. Both these are very valuable and need compensation.

>What are our chances of success?

>My records are already satisfactory.

>Please let me know if you figure out the best country to move to in order to escape corporate fascism.

>Have been defrauded by Medicare and Medicaid many thousands of dollars.

>EM Guidelines may have some uses - but they certainly require some modification and they are being improperly utilized to sort out alleged fraud - based on "cookbook standards."

>Generally the battle is lost when you bring in the lawyers - but maybe you have some good ones, having won the case against Hillary's Task Force.