Pushing the limit. Minnesota probe of Accretive's collection practices raises new questions on hospital billing policies.

The collection practices of hospitals once again grabbed the spotlight, with a report from Minnesota Attorney General Lori Swanson, left, that raises questions about aggressive techniques used by Accretive Health at Fairview Health Services in Minneapolis. While Fairview has already ended its contract with Accretive, a number of large systems still use the Chicago-based billing company.

A case of collegial communication and a patient who does not pay.

Four individuals who teach ethics in dental schools comment on a case in which negative financial information is revealed by one dentist when transferring records of a potential patient to another dentist. All commentators find varying degrees of ethical problem with disclosing such information. Professional codes discourage this practice. All commentators stress the importance of the potential new dentist developing a relationship based on professional standards, with the greatest emphasis placed on the patient's health needs. Several of the commentators discuss positive ways of conducting a patient interview, including specific useful language.

Dental ethics case 6. Stalled payment for ongoing orthodontic treatment--balancing responsibilities.

It is not always easy for an orthodontist to strike the right balance between a caring, supportive and patient-centered approach, and the need to make a living and to run a profitable business in order to achieve this. Striving to act ethically and professionally at all times will help find this elusive balance and ultimately it will be more rewarding and professionally satisfying. Especially when dealing with children whose lives may be dramatically affected by the interruption or cessation of treatment, orthodontists have a duty to reassure themselves about the financial stability of their contractual relationships with patients or parents. Having consistent financial policies and flexible payment options may assist in this regard. Even in the face of non-payment of fees, treatments that have begun must in some form continue if their cessation would compromise the best interests of patients.

A practical perspective on remedial ethics: Minnesota Board of Dentistry.

The President and Executive Director of the Minnesota Board of Dentistry describe how the Bebeau course in ethics, for dentists referred because of ethical lapses, is used as part of the disciplinary process in the state. It is understood that breaches of ethical standards are a complex phenomenon, often engaged in by practitioners who know that they are doing wrong but nevertheless choose to do so. Typical patterns of transgression that result in referral to Dr. Bebeau's course include inappropriate billing practices, improper relations with staff or patients, questionable advertising, substandard care, "rough behavior," and gaps in infection control.

Whodunit? Ghost surgery and ethical billing.

A senior vascular surgery resident started an autogenous radical-cephalic arteriovenous fistula procedure on a comatose patient in the surgical intensive care unit (SICU), expecting you to arrive momentarily. You were nevertheless unexpectedly detained establishing hemostasis in the main operating suite. You arrived in the SICU as the dressing was being applied. Fistula flows were excellent and there were no operative complications. The resident who began and finally completed the case was highly skilled and in the final month of his vascular training; you had supervised his satisfactory performance of many procedures like this one during the last 2 years. The patient's elderly wife had consented to the procedure, which she was told you would be directly supervising while the resident performed the surgery. When the operation was over you met with her to explain your emergency conflict and assure her that you checked the resident's work and found it entirely satisfactory. She accepted your explanation and was relieved that the operation went well. The patient's multiple comorbidities nevertheless necessitated an extended postoperative stay in the SICU, where you personally cared for him. The resident had dictated routinely that you attended the procedure, and your billing clerk had no reason to doubt the operative report's accuracy when she submitted your surgical fees to Medicare and the patient's private insurer, which paid to their contractual limits without challenge. On many occasions you have had your billings shorted by both. The resident since has graduated. What should you do?

Legal. Sharing the bill.

Beset by liability costs, doctors are asking patients to chip in and help pay for premiums. Critics of the maneuver worry that it crosses ethical boundaries and violates business practices.