The question of whether there is anomalous billing in anesthesia care is beginning to be asked by operating room managers, health care administrators, policy makers, and regulators. This question may arise when an anesthesia case seems to take more time to complete than it should.5 Audits, when conducted, have found that an unusual number of claims end with the digits 0 or 5 as if large numbers of cases start or end on the 5-minute mark. Such a finding serves as a red flag for that practice to undergo an audit.6 Questions may also be raised because the percentage of patients coded as having a higher anesthesia risk, using the American Society of Anesthesiologists Physical Status Classification System, has increased from 2.9% in 2005 to 13.2% in 2013, mainly because coding a patient’s physical status at a higher classification or anesthesia risk in a claim ensures better payment of the claim.7
The study by Sun et al8 provides insight into insurance reimbursement fraud, which is facing the health care industry in general. The problem of rounding time using the digit 5 is addressed explicitly in this study, in which the authors estimated the unusually large numbers of cases with durations that were a perfect multiple of 5 minutes for the recorded anesthesia time in several different types of health care settings with functioning operating rooms.8 Of a final sample of 6 261 955 anesthesia cases (from 4221 anesthesia practitioners at 931 facilities in the National Anesthesia Clinical Outcomes Registry), 5% of practitioners reported anesthesia times greater in total than what would be expected across university, community, and specialty hospitals. Furthermore, it was found that the greatest differences in expected anesthesia times were in specialty hospitals compared with university hospitals.8 However, the authors have stressed that their findings should not be interpreted to indicate fraud because fraud involves intent, which could not be determined. Because this study was a retrospective study, the authors could not rule out the alternative but unlikely explanation that the practitioners could be rounding down. The reason for caution by the authors is that the CMS has differentiated fraud from abuse by emphasizing that fraud is intentional, whereas abuse is the result of poor medical practices.2 This differentiation is important because sometimes the rounding in digits ending in 0 or 5 minutes in anesthesia time is part of the organization culture of operating rooms in which rounding is performed systematically by the operation room circulating nurse along with the anesthesia practitioner. Sun et al8 recognized this issue as being related to institutional factors, which was one of the reasons they performed a 2-step regression analysis; long anomalous times were not sufficient to establish inappropriate discretion.8
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