Deciding when a patient is stable enough to leave a hospital is difficult for any doctor, but some former employees of Prime Healthcare Services say the chain has gone to extreme lengths to keep patients at their medical facilities.
Court testimony shows that Dr. Panch Jeyakumar, former medical director at Prime’s Desert Valley Hospital in Victorville, has accused the chain’s founder and board chairman, Dr. Prem Reddy, of overstating one patient’s level of illness in “an economic decision.”
Jeyakumar testified that he and two other physicians, including a cardiologist, believed that one patient who came to Desert Valley had endured a fainting spell.
But Reddy, who had practiced as a cardiologist, got involved in the case and wrote on a patient medical record: “post cardiac arrest – sudden death.”
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Reddy exaggerated the diagnosis to ensure that the patient appeared too sick to be transferred to a Kaiser Permanente hospital, Jeyakumar said, recalling a discussion about the patient during a Feb. 13, 2003, meeting. Other nurse managers gave similar testimony at the trial.
Prime officials would not respond to requests for comment. In testimony, Reddy said he reached the “cardiac death” diagnosis because of the patient’s family history, though he did not document the history in the patient medical record, testimony shows. He also testified that he was angry that Jeyakumar accused him of doing something “immoral, unethical, illegal for a few dollars.”
Kaiser and the Heritage Provider Network have claimed in lawsuits that Prime is playing tug of war with their clients, rendering care without reaching out to their usual doctor or reviewing their medical histories.
Under laws governing how insured patients are treated in emergency rooms, hospital doctors are obligated to decide when an out-of-network patient is “stable.” Once a patient reaches that point, hospitals must give insurance-company doctors information so they can decide whether to send an ambulance to get the patient or authorize the hospital to continue treatment.
Kaiser and Heritage have accused Prime of pressuring doctors not to deem patients “stable” at all during their stay or until hours before they are sent home – and then sending big bills to managed care firms.
Prime denies the latest accusations in legal filings, saying Kaiser’s claims are “demonstrably false” and has accused Kaiser of being too aggressive in bringing its patients back to network hospitals.
Prime accuses Heritage of inappropriately arguing that patients were stable. Both cases are pending in Los Angeles County Superior Court.
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Another former Prime employee said she was charged with asking doctors to “backdate” medical records to get payment from Kaiser. The accusation came from Cheri Boka, who oversaw collections for four Orange County Prime hospitals for 10 months ending in April 2010.
Boka said she called Kaiser to ask about docked payment for patients who came to Prime emergency rooms and were admitted to a hospital floor. She repeatedly learned that Kaiser refused to pay because Prime had not followed regulations that call for Prime staff to discuss care decisions.
In as many as 50 cases, Boka said, her supervisor asked her to copy patient medical records and send them with a blank form labeled “unstable for transfer” to doctors at several Prime hospitals.
The doctors, Boka said, were expected to backdate the form and document information showing that the patients were too medically fragile at the time of treatment to be transferred t o a Kaiser facility.
With the signed forms in hand, Boka said she was expected to submit the bills to Kaiser for the second time.
“It was horrifying,” said Boka, who settled a wrongful termination suit against Prime on an unrelated matter. “I said, ‘This is not right. We’re backdating records.’ ”
Boka said in March that she testified this year about the arrangement in a deposition for Kaiser after the firm contacted her.
A Kaiser counter-lawsuit echoes Boka’s account, saying Prime will seek payment and insert documentation in a medical record to appear as though a doctor made an on-the-spot decision that a patient was not healthy enough to be moved.
“In truth, there has been no such determination,” the lawsuit contends.
The Heritage cross-complaint also accuses Prime of “intentional mislabeling” of patients as “unstable” for transfer even though the patients are well enough to go back into managed care facilities.
Prime has denied allegations in both lawsuits and said Heritage inappropriately claimed that patients were stable to be transferred when they were not.
During a hearing about a proposed hospital sale, Assemblyman Jose Solorio, D-Santa Ana, testified that it is “against California law” to admit patients through the emergency room without talking to insurers.
“Dr. Reddy does this every day in every one of his hospitals,” Solorio said. “In fact, this is how he gets most of his admissions. This should be of concern to the (state).”