Opinion ID: 1864673
Heading Depth: 1
Heading Rank: 4

Heading: Evidentiary Record.

Text: The record discloses testimony by three anesthesiologists besides Dr. Glowacki regarding record-keeping practices. Dr. Marvin Silk, who practices at Mercy Hospital in Des Moines, stated that he essentially charges for the time spent with a patient. He stated that early extubation generally means within two-to-four hours after surgery. The nurses do the extubation after calling the doctor, giving the patient's condition and receiving the doctor's decision to extubate or ventilate the patient. He stated that normally he does not bill for the twenty-four-hour period after surgery in open-heart cases because he considers that as part of the base surgery cost. He stated that there was no question that the post-operative management time spent on the patient by the anesthesiologist is proper billable time and should be compensable. It was not correct or appropriate, however, in Dr. Silk's opinion, to add it to anesthesia time because the reimbursement is different. Dr. William Dipple, called by Dr. Glowacki, who practices in Davenport, testified that the quality of care and services provided by Dr. Glowacki over the years has medically been beyond reproach. Dr. Glowacki was considered to have the best cardiorespiratory dynamics of any anesthesiologist in town. In the early years, Dr. Dipple believed the post-operative respiratory care of a heart patient was two or more hours. This was not one continuous period of time following surgery but involved the physician constantly checking on the patient, back and forth. He observed that during a second surgery Dr. Glowacki would consult by intercom with staff in the ICU on the condition of his first patient. Dr. Dipple knew Dr. Glowacki for over twenty years. He found his character to be of the highest and had no reservations concerning his moral or professional standing. Dr. Alan Sherburne, called by Dr. Glowacki, stated that he practiced anesthesiology at Mercy Hospital in Iowa City. He knew Dr. Glowacki as a resident but had had no contact with him for twenty-five years. He stated that at the time the K codes were used for billing he received a communication from Blue Cross that was a little confusing. He said they never have been very clear about starting or stopping times in these respiratory care codes and never have been very well defined. He stated: I myself would have done it differently. I would have used a respiratory care code. But actually in fact that would have been the effect of charging the patient a lot more, because the base currently for respiratory care under the ASA Relative Value Code Guide is a base of ten for the first day, ten units. And the next day it's five units. And at the time that Dr. GlowackiI understand this covers roughly the mid-eightiesthere was another code from the Iowa Relative Value Guide which most people in Iowa were using at that time, and it had a base of seven plus time. This was the K code which also allowed charging extra units for the sickness of the patient, the lateness of the hour, and for other special circumstances. Dr. Sherburne stated that adding up the time in aggregate for post-operative respiratory care for the average heart patient would equal at least an hour or two. He described the care as a series of discontinuous, sometimes inconvenient visits and phone calls and occasional rushing back. He testified that in Des Moines the anesthesiologist drops things quickly and turns it over to a pulmonologist who handles complete respiratory care. He noted that the pulmonologist was not working the next several days for nothing. Regarding the appropriate billing techniques, Dr. Sherburne said: There are probablywell, I haven't counted them, but four or five different sorts of muddy respiratory care codes and critical care codes that it could have fallen under, and you can make a case that might be logical. And in those cases it would literally pay the physician more than charging as an anesthesia time. Dr. Sherburne made these statements about determining the proper method for billing services. Q. Are there situations in which you have questions about how particular services should be billed? A. Yes and it's very difficult on these critical care things ... and I tried to get through to Medicare to find out how they wanted to charge. And first I called their main number, and that didn't work very well, and you get someone who does a lot of billing. They said resubmit it to the medical department, and three months later you get back saying Medical department has reviewed it. We are correct. So you're left sitting, and they also say that if they made a mistake of twenty dollars, they won't correct it. You have to make one hundred dollars worth of mistakes before you can even have a hearing. Q. Are there ever situations doctor in which you talked to professional colleagues with regard to how they handled similar billing dilemmas? A. It's the blind leading the blind. If you can't call Medicare or Blue Shield and get a straight answer, the people that are paying you, turn to someone else. And they look at this book and say, I don't know. I sent that charge in and they seem to pay it. And there are a lot of confusing codes here that are very, very similar. With reference to Dr. Glowacki's adding time as anesthesia time, he said: It looks to me as if he was finding some way to actually offer reduced fees, and rather than submit a separate charge, which actually would have been more, he just tacked it on. I wouldn't have done that, but I probably would have used the other codes, but there are a lot of different ways to bill for it. Dr. Gerald Davies, an anesthesiologist practicing in Davenport who had been an assistant professor of anesthesiology at the University of Iowa Hospitals, testified that Dr. Glowacki was a good physician by any standards. He described him as a caring physician, very well-liked and respected with a sound practice. Dr. Davies was asked at what point did he cease billing for actual administration of an anesthesia. His response was: I thinkwouldn't it be reasonable to continue that until you cease to be in personal contact with the patient? That would be reasonable, and that's what I do. The only problem with that is: what if you go backyou know, what if you go back to see the patient maybe two times after you finish anesthesia? How are you going to bill for that? It gets a little bit messy when you are putting in fifteen minutes or a ten-minute period when in fact you visited the patient a couple of times. And that was Dr. Glowacki's problem. You know, you say you were with the patient from seven until ten thirty, and you visited the patient maybe at one or four in the afternoon for a period of time. You know, including that time in the bill, it just becomes unwielding, messy. On the question of charges for medical services Dr. Davies estimated that Dr. Glowacki's charges were about one-half of the amount charged at the University of Iowa Hospitals. In its findings of fact and conclusions of law, the panel of the Board of Medical Examiners noted that three medical doctors testified that Dr. Glowacki was an honest and respected physician. The board's decision also noted Dr. Glowacki's reputation as a competent, caring, and respected physician. The board specifically referred to the question of whether post-operative respiratory services provided to patients undergoing heart surgery could be separately billed or were an integral part of the anesthesia charge. Dr. Silk opined they were an integral part of the anesthesia charge, while Dr. Davies and Dr. Sherburne disagreed. The board thereafter concluded the board will not resolve the billing dispute among anesthesiologists and, therefore, does not find the respondent guilty of knowingly making fraudulent representations in the practice of medicine. Inherent in this finding is the conclusion that Dr. Glowacki was not guilty of billing for any services to which he was not entitled.