It was not unusual for John Natale, MD, to work from early in the morning to late at night at his cardiothoracic and vascular surgery practice in Arlington, IL. A decade ago, the 63-year-old physician might have been at the top of his game. In particular, he was credited with saving five patients' lives through complicated repairs of abdominal aneurysms.
While Natale distinguished himself with one facet of the Hippocratic Oath, he was certainly not as precise in another more mundane code of conduct that touches on every physician's practice: preparing billings and coding.
Natale says he made simple mistakes. The government believes the doctor tried to rip off taxpayers.
Last year, government prosecutors accused Natale of fraud for using CPT (current procedural terminology) codes that allegedly represented more complicated procedures than the surgical ones he performed. By using such codes on operative reports, he would ostensibly collect higher reimbursements as a result.
Natale is now serving the third month of a 10-month prison sentence after being convicted in U.S. district court last November of two counts of making false statements in connection with surgical codes submitted between August 2002 and October 2003. He was acquitted of two counts of Medicare fraud.
Prosecutors and the Association of American Physicians and Surgeons agree that Natale's case should have a profound impact on physicians. They disagree sharply over what that message is.
"The need for deterrence is very strong in a case like this," said U.S. Attorney Amarjeet Singh Bhachu when Natale was sentenced. "A message needs to be sent out to doctors." The sentencing judge, Rebecca Pallmeyer, noted that "accurate coding is of extraordinary importance."
"The message to doctors is not to take Medicare money," Jane Orient, executive director of the AAPS, told me. "If you take it, you must comply perfectly with requirements, and this is impossible. They can't prosecute everyone of course; they could prosecute anyone."
The AAPS has joined in an appeal of Natale's conviction. It said that the criminalization of language used in medical reports would have a profound impact on the practice of medicine.
"The chilling effect caused by this conviction, if upheld, is undeniably profound for many physicians," the AAPS stated in papers filed with the court. "Physicians will now need to practice 'defensive documentation,' taking more time away from patient care in order to double-check and triple-check their operative notes—or say less in their notes—lest a few inevitable errors be used to incarcerate them and destroy their careers."
"This precedent criminalizes false statements in a private setting without any proof of billing fraud and a greater interference with the day to day practice of medicine is difficult to imagine," the AAPS added.
The criminal case stemmed from the surgeries, and coding, that Natale used a decade ago. Natale made "difficult, life-saving operations" and routinely worked extremely long days, but was consistently behind in dictating his operative reports, according to Orient.
Under federal billing requirements, physicians are required to use AMA-copyrighted codes. Natale allegedly incorrectly stated that he had used a bifurcation or Y-graft in repairing an abdominal aortic aneurysm instead of a straight tube graft actually used. Natale made errors in the reports, according to Orient.
For his part, Natale testified that he was instructed to use similar codes if he couldn't pick the right ones.
"These surgeries in question were done 10 years ago, and the doctor was an extremely busy surgeon from 5:30 a.m. until late at night, chronically behind on his operative reports," Orient says.
"When you dictate late, you are more likely to make mistakes, and when you look at the (Natale operative) report, there were mistakes, parts were incorrect. An essential part of the report is difficult to understand, or is easily misunderstood. Doctors aren't all that great at writing. And he just did a lousy job of explaining, but he saved patients' lives. He saved lives and he's in prison."
Orient says Natale made errors in "two of 2,400 operative reports." That, she says, is "apparently now a federal crime, though the doctor's total charges were much less than he could have lawfully billed." She did not reveal the total charges.
The complexity of the coding and the requirements of the physicians didn't seem to be the problem, as far as the sentencing judge was concerned. "It's hard for me to imagine that there was some motivation other than to pad the bill in Dr. Natele's operative notes," said Judge Pallmeyer in her sentencing report.
Since Natale has been imprisoned, Orient hasn't talked to him, but has stayed in touch with his family. Natale is trying to stay busy in prison by teaching GED students, and "reading as many books as he is allowed to have," she says.
Natale has appealed his conviction, but the odds are that "he will probably never practice medicine again," Orient says.
"Who would want to," she asked, "when you can go to prison—for paperwork errors—10 years after you saved patients' lives?"
Joe Cantlupe is a senior editor with HealthLeaders Media Online.
