March 22, 2011, 4:25 pm

Fraud or Abuse? Either Way, No Pay

And the winner for Best Posture in a Student Nurse goes to…..

I wonder what they are doing here? It does look like they are all standing at attention.

I’ve been trying all day to think up hilarious dialog for this pic but nothing is coming to me. If you think of any, have at it in the comments. Of course, the minute I post this, I will think of a bazillion of them.


Grand Rounds is up at Better Health!

I actually managed (barely!) to sneak in a post this week!

It is a fantastic edition with some new (to me) blogs and lots of old favorites, so grab a cup of coffee (the best way to enjoy the Rounds!) and check it out!


We hear so much about health care fraud and how much it costs us all in terms of higher Medicaid, Medicare and private insurance costs, and if we could just rein in this fraud we could make our health care system pay for itself.

My trusty Mac widget dictionary defines fraud as:

  • a person or thing intended to deceive others, typically by unjustifiably claiming or being credited with accomplishments or qualities and
  • wrongful or criminal deception intended to result in financial or personal gain.

Well, I’m wondering, what is actually considered fraud?

Let me give some examples, and help me understand whether or not this is fraudulent behavior. The examples are purely hypothetical and do not represent any known individuals, living or dead, or specific situations in any known emergency department, living or dead.

  • A patient covered under Medicaid utilizes the emergency medical system by calling 911 for transport to an emergency department to obtain a refill for a non-emergent medication (ie, not insulin).

Fraud? If the patient does not claim an emergency problem, there is no deception, ergo no fraud. But if the Medics can’t triage this call out (aka, say “HELL, no!”), there is a $1000 ambulance bill and it’s at least $1000 to walk in the ER. The patient pays nothing. If this isn’t a fraudulent use of the EMS system, what do we call it, abuse? Abuse for personal gain?

  • A parent walks in to the emergency department with his eight children, all of whom are covered by Medicaid. He wants all eight children seen for colds. It is the middle of the day. The local pediatric clinic is open. It is ascertained that the clinic will see all the children later in the day. It is also ascertained that the father is aware that the cost of seeing the eight children will be one hundred times higher in the emergency department than in the clinic. The response is “I don’t care. I’m not paying for it.”

Fraud? Again, no claim of an emergent problem, so no fraud by definition. But the ED cannot, by law, turn the father and the children away, at least here in CA. So, if the cost of a clinic visit is $20 (for example) and the total visit for each child in the ED is $2000, that’s quite a bill that Medicaid now has to deal with. Again, if it’s not fraud, do we call it abuse for personal gain?

  • A patient covered by Medicaid utilizes the EMS system for transport, requesting a hospital quite a distance from where they live. The chief complaint given the paramedics is not the same complaint they state on arrival. The revised complaint would have required the medics to take them to the closest hospital. This is the fifteenth visit in four weeks. All by ambulance. Given the patient’s history and the chief complaint on arrival, most ED docs feel obligated to at least a minimal work-up. Multiple doses of narcotics are required. Lots of narcotics. Gallons of narcotics. Hour are spent. Disposition is always discharge.

Fraud? I’m calling yes on this one. Patient wants a specific facility, knows how to get there by not using an emergent symptom until arrival – that is deception, at least. It’s drug seeking, and drug seeking is fraud, hands down. But how do you prove it? In this example, the patient is racking up tens of thousands of dollars in medical bills on a weekly basis. The medics can’t refuse to transport the patient, the facility can’t refuse to see the patient (although slowing down on the narcotics might slow down on the visits, no?) It’s deception for personal gain – so a fraud vote for me.

  • Patient needs a procedure. It is not emergent. Patient is not dying. Patient is perfectly fine and stable pre-op. Procedure is actually scheduled. But in order for the private insurance company to cover the procedure, the patient must be admitted through the emergency department, and actually go to the procedure from the ED. So, a full triage is done. An IV is inserted. An ED charge goes on the books.

Fraud? Oh hell, yes. Would someone explain to me why this is not fraud? If you need a procedure, you go the normal route like everyone else. This pretending you had to come into the ED first is a bunch of bull***. Good thing I never see it (cough) because I sure as hell would have nothing to do with it.


Now that I look over these examples, I see more abuse than I do actual fraud.

Either way, it is a ton of waste.

How do we stop it?

They don’t let us stop it on site. We cannot turn away non-emergencies. Medics cannot refuse to transport.

Look at fraud, yes, but do something about the abuse of the health care system, too.

There is no penalty for abusing the system.

In fact, I don’t think people even recognize that they are, in fact, abusing the system.

I think they see it as their right to use it as they see fit, no matter what the cost. It’s there to use to their convenience.

And it doesn’t matter if it’s Medicaid, Medicare or private insurance!

Until people stop seeing their healthcare as being provided for free, there is no incentive to use it efficiently.

When you don’t have to pay the Piper, you don’t care what tune he plays.

March 21, 2011, 5:07 pm

RN-to-Infinity And Beyond

Ah, another exciting Saturday night at the nurses’ residence!

I’d love to make fun of this, but I was geeky enough to view this as absolute heaven at thirteen years old!

Living in the dorm, wearing my cape (and lord almighty wearing my cap!), being casually professional and just all that and a huge bag o’ chips!

And I’m still geeky enough to love every bit of it. Including the dolls on the shelves!

Found the picture in the Library of Congress collection. Bless them. What a treasure trove!


I’ve been sitting here, sort of quiet, watching the blogosphere.

Watching nurses take up the eternal discussion of entry level into practice. It’s been around forever. I have articles from the American Journal of Nursing from the 1940’s talking about an entry level BSN. I wrote an article about the impending demise of ADN programs for my college newspaper in 1977.

My ADN instructors were rather amused.

I’m sensing a change in the tone of the dialog since the release of the Institute of Medicine (IOM) Report on the Future of Nursing, with its focus on “seamless academic progression” (p. 163). The goal is a nursing workforce that is 80% BSN prepared by 2020 (p.173), including currently licensed RNs.

This encompasses all of today’s nursing force, taking this highly educated, experienced group, recognizing the value of (and the need for) advanced education and developing the current workforce while the future of nursing education is redesigned.

It takes the focus off of where you started and puts the focus on where you want to end up.

And that, my friends, is huge.


Remember the bad old days when it seemed like ADN = BAD! BSN = GOOD! MSN = BETTER! DNP = SAINT! PHD = GOD! LOL! Now, instead of seeing fierce turf wars and nurses at each others’ throats fighting to defend how well prepared they are or how they are just as good as another nurse with a higher degree…

All I hear now is……quiet.

Quiet…contemplation. And, yes, believe it, civil discussion!

For someone who participated in, and triggered, a few of the heated versions, this is amazing!

I swear, you live long enough, you really do see it all!


And I hear questions.

Why? Why should I get a BSN? What would I do with an MSN if I did get it? I don’t want to teach, or be a manager. What else is there? Is it worth the money?

Well, as someone who was never, EVER going to darken the hallway of a BSN course as long as she lived and who is now applying to MSN programs, maybe I can provide some perspective.


IF you are looking for a bigger paycheck or a huge pat on the back and a sparkle in the eye of your employer, well, you won’t find it by adding alphabet soup after your name. I’m just bein’ real, as Randy Jackson would say.

On May 13th, 2010 I went to work as an ADN and on May 14th I went to work as a BSN. My pay was exactly the same. My patient assignment was exactly the same. My name tag now said “RN, BSN” and I received a heartfelt “Congratulations!” from my co-workers that night and my boss in the morning. [crickets]

The immediate external rewards were few.

The internal rewards are innumerable:

  • A sense of accomplishment. I have a stunning diploma that I still stare at with a stupid grin every time I enter the den. I am so proud of the work, dedication and stamina that went into actually earning that BSN after 31 years of nursing.
  • A better understanding of the complexity of our health care system and nursing’s place in that system. My perspective has broadened, my public health experience linked health disparities to economic and educational disparities in a clear, visceral fashion. Anyone can learn about it. My program educated me on what can be done about it.
  • A heightened sense of professionalism. I’ve always been professional. I am now a Professional. It’s hard to describe, most of these intrinsic changes are, but there is something in the BSN curriculum that broadens the understanding of Nursing as a profession, the place of Nursing in health care and the place of individual nurses as health care leaders.
  • A better nurse. I was good before. I’m better now. I see the whole picture. I thought I saw the whole picture, but I didn’t know enough to know what the whole picture was. It’s like playing Angry Birds on an iPhone. You can be great at it, but then you get an iPad and you see things you didn’t know were there. You know what to shoot for. You know where to aim to hit the Pig.


Okay, that was a little simplistic.

What I’m trying to say is this: the rewards that come from getting an advanced degree in nursing are going to be intrinsic, at least at the beginning. The better opportunities, the offers you could not consider before, those will come later. At first, you are going to have to want this for you.

Your coworkers, your manager, your employer, they will think it is very nice. And that’s the last you will hear of it. Or they will tell you you’re nuts for spending the money for nothing, that they have better things to do with their time and their paycheck.

I will tell you that you will experience an unbelievable personal and professional growth that you cannot even imagine right now. I can’t even explain it because it is different for each one of us. And that’s just what you will get out of it.

It’s a win-win situation. You get personal growth. The nursing profession wins through your education.

Now multiply that by every single patient you take care of for the rest of your career.

Now tell me it isn’t worth it.

It’s so worth it I’m onto an MSN in September!

What are you waiting for?


Committee On The Robert Wood Johnson Foundation Initiative On The Future Of Nursing, At The Institute Of Medicine (2011). Transforming Education. In The future of nursing: Leading change, advancing health. (pp. 163-220). Washington, DC: The National Academies Press.

March 9, 2011, 7:55 pm

If You Can Make an Appointment, YOU DON’T NEED AN ER!

Get 15% off hospital scrubs with code “white_onsale

I want to give a huge shout out and thank you to Scrubs Gallery for their continued support of Emergiblog through their advertisement, and new to 2011, their monthly sponsoring of an Emergiblog post. Thanks, Aaron! You guys rock!


Well, I am happy to say that I am NOT old enough to remember when cardiac monitors were simply oscilloscopes.

Is it just me or does that uniform look extremely uncomfortable? It’s like she has a restraint around her waist. If it gets any tighter it will blow that cap right off her head!


Congratulations to Krista Casey, who won the free copy of Jennette Fulda’s latest book, “Chocolate & Vicodin”!

Krista, your book should be on its way from the publisher.

Many thanks to all who entered the Emergiblog drawing!

Chocolate & Vicodin: My Quest for Relief from the Headache that Wouldn’t Go Away is available from and other booksellers.


I actually wrote this post in November.


Why I did not post it then, I do not know, but here it sat in my pile of drafts, neglected and unattended.

It’s still relevant, so I’m posting it now.

(Hat tip to the Emergency Nurses Association’s Facebook Page for this information. The article can be found here.)


This is so wrong.

You can’t make this stuff up.

It seems an emergency department in Memphis, Tennessee is now taking online reservations for their services. Yes, you heard that right, you can now hop online and select the time you would like to be seen for your “emergency”. Just pay $15.00 and you can give your chief complaint, your medical history and your list of medications ahead of time, saving you time and trouble when you pop in with your pesky problem!

What if the problem is serious?

The computer won’t let you register and flashes a “Call 911” sign at you.

But wait! There’s more!

If you are not seen within 15 minutes of your scheduled time, you money is cheerfully refunded!

I’m not kidding.


If you can make an appointment for an ER visit, you are not having an emergency!

Repeat it with me: the use of emergency departments for non-urgent problems is an inefficient, expensive practice.

If you are making an appointment for an “ER visit”, what you are doing is making an appointment for a clinic masquerading as an ER. And if the “ER” actually a fast track that is staffed and run separately from the ER (aka an “urgent care” or a “clinic”) then, don’t advertise it as an emergency service.

The very nature of emergency care means never knowing what will come through the doors or when it will show up. The patient population is fluid, the acuity level varies widely with no way to predict work flow. You can make appointments and schedule to your heart’s content but all the online reservation systems in the world cannot guarantee that an emergency department will be able to see a patient in a set time frame.

And the “money back” guarantee?



How can we expect the public to have realistic expectations of health care, specifically emergency care, when it gets treated like your local nail salon? Make an appointment and get your money back if the totally unreliable, unforeseeable and often chaotic world of the ER can’t meet its promises.

It’s bad enough that patients have unrealistic expectations when they walk through the door. They expect to be seen instantly. They don’t expect to wait for labs. They want meds given to them and not to have to go to the pharmacy. And now, in a community in Texas, they can make an appointment to be seen in an emergency department.

I wonder if the nurses and doctors on the front lines had any input into that.

I don’t have much information, but it just reeks of corporate input.

Maybe I’m missing something, but I just don’t get it.

About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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