Just Be Ethical

I recently recovered from a case of being “O-less.”  No kidding.  The “O” on my laptop keyboard dislodged and wouldn’t reseat.  Here is a portion of the actual chat session I had with my computer manufacturer’s tech support:

Me: “Hi. The “O” on my keyboard has detached and will not reseat – I already viewed the online Tutorial.”

Agent: “Hi Christopher, not to worry, I will be glad to help you.”

Me: “Thank you”       

Agent: “So, what I understand is that the letter O has been detached from the keyboard, am I correct?”

Me: “yes”

Agent: “Okay, and how did that happen?”

Me: “no clue”

Agent: “I see.”

Me: “perhaps I have unique thoughts that detach keys when I type”

Please pardon my obvious sarcasm, but what was I to say?  I was using the laptop to squash bugs or hammer in a nail which subsequently led to the displacement of the “O?”  In retrospect, I could have also named a particularly rough session of cybersex as the culprit.  You would need plenty of “O’s” in such an exuberant endeavor.  Since she didn’t seem to find the “unique thoughts” suggestion amusing, I doubt she would have found that one any more humorous.  She went right into problem-solving and checked my warranty.  My warranty is still in effect and a very nice technician stopped by my work and replaced the whole keyboard at no expense a couple days later.  Now I again have complete command of the English language at my fingertips.  This is a great county after all as Yakov Smirnoff used to say.  This was great customer service and I hope to get a survey with which to praise the contracting technician’s business.

I have customer service and ethics on the mind.

Last year I was working with a wonderful lady in her 80’s who was still fiercely independent and being treated for a bone marrow cancer, multiple myeloma.  It would fair to say that I loved this lady.  She called me to ask my advice and help with many things including getting a refund on a plane ticket (she couldn’t travel anymore) which I successfully got for her.  For this I got frequent kisses on the cheek.  She was in a state of decline but was still physically capable of meeting her activities of daily living.  So, she didn’t qualify for specialized services from the appropriate state agency.

As this was happening her son did some calls of his own after receiving a recommendation from her landlord to call a local hospice agency.  This agency had several tenants on service.  The son talked to an admissions nurse who subsequently called me asking for the doctor’s order to start services.  I informed her that she was still getting active treatment and I knew for a fact due to my close relationship with her that she was not ready for hospice care.  Then I educated the son about the services and that it would mean that she would need to no longer seek curative treatment.  He agreed with his mother’s intent and called the nurse back and told her that they did not want the service.

I wish the story ended here.

Flash forward three months.  In the midst of a conversation this lovely lady tells me that she is still getting in-home nursing and thinks it is coming from the health care system for which I am employed.  I check and they say she has not been on service in months as they did only short-term services following an in-patient hospital stay.  At my request she brings in a folder from the very hospice agency which had been declined.  Further digging on my part reveals that two weeks after my (and the son’s) call to the admissions nurse she sent on a request for order directly to the doctor with a claim on the fax sheet that the family was requesting service.  The doctor signed an order without verifying with the patient or family.

Did I mention that she had mild dementia?  The hospice agency met with this woman alone and she signed the admission papers.  She thought it was my health care system providing the service because her doctor signed the order.  Nothing else changed – she still got her treatment through my clinic.  Here’s the problem: You shouldn’t be double billing Medicare when the hospice benefit is activated – our clinic billed for active curative treatment while the hospice agency was billing for palliative end-of-life treatment.  That would be a no-no.  It could lead to lots of billing problems resulting in a possible legal dilemma.  Either the hospice agency would have to authorize (and pay for) the potentially expensive chemotherapy not designed for palliation or both are billing independently of the other.

I sat down with the patient and son.  I explained the differences between hospice care and curative treatment and they were both shocked and unhappy with what they determined to be deception on the part of the hospice agency.  The lovely lady was confused at times and didn’t understand the implications while the son just thought it was an in-home nurse checking on his mother.  He told me that they weren’t talking to him at all.  The whole point of hospice is to work with the patient AND family to deal with comfort, end-of-life, grief, etc.  It’s supposed to be a team effort that includes the family.  He was her primary caregiver yet he was left in the dark (as was I).

Needless to say, I was unhappy too.  I called the hospice’s local director to inform her.  When I mentioned the lady’s name she clammed up and told me she couldn’t talk to me for confidentiality reasons.  Mind you I was calling as a representative of the doctor who ordered the service and who had retained custodianship of her care – HIPAA (The Health Insurance Portability and Accountability Act of 1996) regulations would clearly allow this kind of information sharing on behalf of the patient’s care and treatment plan.  She said she would call and get permission to talk to me.  Within an hour she called back much more receptive after apparently speaking to the son.  She explained to me that hospice’s services were far more open than in the past and that it was I who didn’t understand what they could do – no mention or explanation for the manner in which they put her on service.  At this point I informed her that following our last call I had made a report about their behavior with the state regulatory agency that oversees hers.  Her response: “Then I have nothing more to say to you,” and she hung up.

At my recommendation, the patient and son called and informed the hospice agency that they wanted to end the service ASAP.  Within the day a worker came out and termination papers were completed.  A couple months later I received a letter from the state regulatory agency indicating that they could prove no formal charges as the patient was not determined to lack capacity and she did sign the papers.  But there were billing questions that warranted a referral to the appropriate federal agency.

Shortly thereafter my lovely patient passed away suddenly and quietly while in-patient in the hospital.  It was at that point that they were considering nursing home placement as she had reached a stage where she couldn’t be discharged home.  It could be said that she died on her terms and had remained independent until the end.  I still miss her and was happy to have attended her funeral to say good-bye.  It was gratifying to hear the appreciation of her family.

A week or so ago I made a referral on behalf of another patient to a different hospice agency.  They informed him that could not pay for his current pain medication because it was out of their regulated budget to afford.  It is still undetermined that he will go on service.  Now look at the difference here: the second agency is transparent and straightforward in telling the patient what their limits and policies are.  They informed me promptly of this situation and are trying to work with the patient to provide services, but won’t make promises they can’t keep or act in any deceptive manner just to get the person on service.  That’s what I call honest and ethical business practice.  While I won’t name either agency here, I will volunteer that the second cared for my Mom when she died.

Just be ethical and aspire to provide great service.  It builds solid bridges with your clients and referring partners.  It makes you stand out as having integrity and others will trust your decisions.  It’s just good sense and you will be known as having vision instead of narrow greedy ambition.

This is dedicated to Dorothy.

Christopher David

March 18, 2010