Which Comes First, the Patient or...?

James Sullivan was admitted to Springfield General Hospital on March 15 with chest pain, had a cardiac catheterization that demonstrated significant blockage, underwent a three-vessel coronary artery bypass graft, and experienced numerous postoperative complications that required many returns to surgery. Mr. Sullivan also experienced a cerebrovascular accident that resulted in dysphagia. This led to aspiration pneumonia and respiratory failure, necessitating ventilator support.

Mr. Sullivan was discharged from the acute care unit and admitted to the hospital skilled nursing unit on June 29 for rehabilitation after his hospitalization. The charges on the account for Mr. Sullivan's admission were over $400,000. Coders at Springfield General have always been under great pressure to keep the inpatient unbilled accounts under $750,000. Before Mr. Sullivan's discharge, the unbilled accounts report was at $925,000; when he was discharged, the amount grew to over a million dollars.

The following morning, the coding supervisor, Carma Davis, was called to meet with Fernando Sanchez, the Chief Financial Officer of Springfield General. He told her that he expected the Sullivan account to be coded and billed before the end of the day because this was a critical financial time for the organization. She assured him that she would personally take care of it.

Carma was well aware of the hospital's financial situation. Weekly analysis of the organization's accounts receivable had recently been replaced with daily analysis and midday reporting of coding productivity. Rumors of layoffs were spreading like wildfire. Carma, being in a lower management position, was in constant fear of her position being eliminated.

Carma felt the need to not only get the account coded but also felt she needed to prove her abilities and worth to the organization to Mr. Sanchez. She tracked down the chart immediately after meeting with Mr. Sanchez and planned to get the chart coded herself. Due to all of the procedures and complicated diagnoses, Carma knew it would take her most of the day to get the chart coded, especially without properly assembling and analyzing it.

At 11:30 that morning, James Sullivan was readmitted to acute care with a dissecting abdominal aortic aneurysm, requiring emergency surgery. Dr. Hanson called for the record from the previous hospitalization, which Carma promptly sent to him. Fernando Sanchez contacted Carma at 3:00 p.m. to check the status of the large account on the unbilled accounts list. Carma informed Fernando of the situation, but he was not sympathetic. He insisted that she would stay at work until that account was billed.

Additional complications arose for James Sullivan, and additional specialists were called. Carma made numerous attempts to get the record and was even willing to work on it in an intensive care unit (ICU) area. Carma went to see Mr. Sanchez regarding the situation, only to be told that it was not his problem how she got the chart done and that he expected that account to be billed before the end of the day.

When Carma went up to the ICU, she encountered a physician who became very angry with her interference with the patient record and told her that financial obligations were not to interfere with patient care needs. Carma returned to her department and was called into her director's office. Keyanna, the Director of Health Information Management at the facility, informed Carma that she had received a call from the ICU nursing supervisor with a complaint about her interfering with patient care to get a chart for coding. Carma told Keyanna that Mr. Sanchez had insisted that the record be coded by the end of the day. Keyanna told Carma that she would contact Mr. Sanchez about the situation and work things out with him.

After Carma went back to her office, Keyanna visited Mr. Sanchez. Keyanna explained that she understood that the Sullivan account was significant on the accounts receivable. Still, she explained that the patient's health situation required all physicians involved in his care to have immediate access to the health record without interference for administrative, and financial purposes. However, Mr. Sanchez did not respond sympathetically to the situation as Keyanna had anticipated. Mr. Sanchez told her that the institution's financial situation was at the point where reduction would be necessary and that if the Sullivan record were not coded and billed by the end of the day, then Keyanna would be required to eliminate Carma's position.

Discussion Questions

1. What internal and external forces impact this case?
2. What are the legal issues addressed in this case?
3. What are the ethical issues addressed in this case?
4. How are the ethical issues in this case covered in the American Health Information Management Association Code of Ethics?
5. Is there anything that Carma could have done differently in this case?
6. How should Keyanna respond to Mr. Sanchez's final statement?
7. Using the case method, evaluate possible actions that should be taken and determine the best option.