Sneezing or itching with allergies? Your GP will refer you to an Allergist. This specialist will test to find what materials you react to, then will plan a series of allergy shots to desensitize you. The initial dose level is tiny, and gradually builds up over time. For a year or more, you receive these allergy shots at the specialist's office so that your feedback can guide the treatment plan.
After you reach your maintenance dose, your Allergist will write out a schedule to follow, and send you back to your GP to continue your allergy shots. The Allergist lays all the groundwork, thus for the family doctor an allergy shot is a quick two-minute procedure. The medication cost is borne by the patient, as you purchase your own vial of serum. The Medicare fee code reflects these facts.
My case: I consulted allergist Dr. Larry Hardy, then purchased my own serum and visited Pleasant Hill Plaza Medical Centre for my maintenance level allergy shots. But this Clinic inflated their bill for 43 of my injections over a four-year period. In Saskatchewan, a single Hyposensitization Injection has fee code 113A, at a cost of $4.80. Yet the clinic unlawfully claimed fee code 5B and collected $18.75 for each allergy shot. (Source: Payment Schedule 1991)
Fee code 5B is actually a Partial Assessment, and involves considerable work described in the fee guide as: “History review, history of presenting complaint, functional inquiry, examination of affected parts or systems, diagnosis – assessment, record, necessary treatment, and advice to the patient.”
The proper code for an allergy shot is 113A. Billing it as 5B gives the GP four times the income he is entitled to. Such ‘upcoding’ is unethical. When I reported the fraud to the College of Physicians and Surgeons, Registrar Dr. Loewen wrote: “I indicated to Dr. Howlett that they should reconsider this and discuss the matter with the Saskatoon Medical Association which is the economic arm for physicians in the province. I am still awaiting his reply.” … and still waiting
D.A. KENDEL, M.D.
Direct all correspondence
to the Registrar
Physicians and Surgeons
G.W. PEACOCK BUILDING,
211 - FOURTH AVE. SOUTH,
SASKATOON, SK S7K 1N1
Business: (306) 244-7355
Facsimile: (306) 244-0090
OUR FILE: Howlett, E.
Mrs. Georgena S. Sil,
P.O. Box 1491,
Dear Mrs. Sil:
I have now concluded my investigation of your concerns raised in your letter of October 22nd, 1996.
A reply was received from the Pleasant Hill Plaza Medical Centre through Dr. E.J. Howlett. Dr. Howlett has indicated that in their Clinic the physicians provide the injection rather than a nurse. He states that the physician is responsible for:
In addition, when you come to the office you are registered, the computer record is accessed by the office staff and the chart is pulled from the filing bank. After the injection the patient is observed in the waiting room for a time to determine if there were ill effects related to the injection. Dr. Howlett has indicated that in view of the above, they believe that a 5B fee is reasonable.
I have indicated to Dr. Howlett that he should reconsider this and discuss the matter with the Saskatchewan Medical Association which is the economic arm for physicians in the province. I have been awaiting his reply after he consulted Dr. Scharfstein, but have not received it. Therefore, I am sending this letter, with a copy to Dr. Howlett, to remind him that I am still awaiting his reply.
L.M. Loewen, M.D.
cc: Dr. E.J. Howlett
Pleasant Hill Plaza Medical Centre
1623 20th Street West
Competent caring Physicians providing quality health care.
ROYAL COLLEGE OF PHYSICIANS
& AND SURGEONS OF CANADA
774 Echo Drive
Ottawa, Ontario K1S 5N8
I am writing to express my concerns about the billing practices at Pleasant Hill Plaza Medical Centre, Saskatoon. Their full address is: 1623 20th Street West, Saskatoon, Saskatchewan, S7M 0Z7. (Note this clinic is easily confused with a second clinic with almost identical name – ‘Pleasant Hill Medical Clinic’ – located across the street. These clinics are not branches of one another.)
Pleasant Hill Plaza Medical Centre (PHPMC) accepts walk-in appointments, making it a convenient place to go for allergy shots. Pleasant Hill Plaza Medical Centre, however, bills in excess of the procedure when a patient attends for only a routine allergy shot. PHPMC bills $18.75 (implying a full office visit) for that two-minute allergy shot, although nothing else was requested or done except the allergy shot, and although other clinics bill only $4.70 for the procedure.
Between 1989 and 1993, I had my allergy shots at the Pleasant Hill Plaza Medical Centre. Some background: I contracted Guillain-Barre syndrome in September 1989. I was instructed to stop any allergy shots for the next 1½ years, to avoid triggering my immune system. Then in March 1991, I visited allergist Dr. Hardy of Saskatoon, who supervised the resumption of my allergy desensitization treatment. Dr. Hardy advised me to drop down two dilutions, and gradually build back up to my usual maintenance dose. Dr. Hardy did the assessment, and wrote the dosage schedule. There was nothing for Pleasant Hill Plaza Medical Centre to do but follow the schedule presented them.
The initial dose was small, thus the first shots did not last very long. As well, the process of building back up to maintenance was a long one, and Dr. Hardy instructed I could have the shots as often as twice/week. During this phase, between 1989 and 1993, I had my allergy shots at the Pleasant Hill Plaza Medical Centre.
And between 1989 and 1993, the Pleasant Hill Plaza Medical Centre billed for a full office visit on 43 separate instances when I attended solely for my allergy shots. Attached is a Statement of Medical Services from Saskatchewan Health, with those 43 instances highlighted in yellow.
Apart from allergy shots, at no time did I request or receive other medical care, or treatment, or discussion, from Pleasant Hill Plaza Medical Centre. I had a regular family doctor in Dr. W.H. McKee of Saskatoon, who took care of my autoimmune diseases and any other aspects of my medical care. I attended Pleasant Hill Plaza Medical Centre only for my allergy shots. This arrangement had the blessing of Dr. McKee since the shots were frequent, and PHPMC was conveniently located just around the corner from my home.
In this light, the reasons given by Pleasant Hill Plaza Medical Centre for their billing practice are infuriating. When challenged as to what circumstances lead them to bill for office visits as often as twice per week, PHPMC replies “Oh, some patients go from doctor to doctor looking for someone to tell them there's something physically wrong with them.” Or they reply, “Most patients aren’t really ill. They're just anxious and drop in to chat.”
Neither of these excuses is true. To demonstrate this, I have applied for, and enclosed, a copy of my medical chart from Pleasant Hill Plaza Medical Centre. Each of my attendances at the clinic is recorded in the chart as a quick, routine allergy shot following the schedule provided by Dr. Hardy. To demonstrate further, I have enclosed a copy of an article I published in The Medical Post, describing my experience with Guillain-Barre syndrome. This article will, I believe, show that I am an independent and resourceful patient, not given to over-visiting doctors in the manner portrayed by Pleasant Hill Plaza Medical Centre.
Note: The names of the doctors at PHPMC vary because allergy shots are not considered ‘continuing care,’ and the patient is shown in to whichever doctor has been assigned the walk-in duties that day. The names of the doctors at PHPMC who over-billed include Dr. E.J. Howlett, Dr. S. Flegel, Dr. I.C. Waddell, Dr. R.J. Shyleyko, Dr. M. Smylie, Dr. J.W. Melenchuk, and Dr. C.T. Chase.
Five months ago, I wrote to Saskatchewan Health outlining my concerns. (A copy of my letter is enclosed). Since I have received no reply, I felt perhaps I had forwarded the information to the wrong agency, and that my inquiry could more appropriately be handled by the Royal College of Physicians and Surgeons.
Georgena S. Sil
Tuum Est - It Is Up To You
Old Town Hall, Prague
Laws and institutions are constantly tending to gravitate. Like clocks, they must be occasionally cleansed, and wound up, and set to true time.
Henry Ward Beecher
In Saskatchewan, the branch of government that sets the fees physicians may charge is:
Medical Care Insurance Branch
Saskatchewan Ministry of Health
The fees in effect at the time Pleasant Hill Plaza Medical Centre committed their fraud are set out in these legislative documents:
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