It’s All About Orders

As we often like to remind our payers, even though DME suppliers are treated and reimbursed as if we are simply an equipment rental company, we are much more than that. As a part of the health care delivery system, we have additional responsibilities beyond simply filling out a rental agreement. While many retail items are available for cash purchase, customers cannot rent or purchase a legend item, or bill an item to their insurance provider (when they are permitted to do so), without following the required steps. These always include a complete written order by the prescriber prior to delivery (WOPD). As much as DME providers struggle with audits, competitive bidding and more, prescribers must also contend with the threat of fraud indictments for signing orders for patients they don’t follow or for whom they do not manage the care. Now enter the hospitalists. Hospitalists are physicians hired by and employed full-time at a hospital. They do not have private practice offices, nor do they see patients for visits and check-ups. They are found in most acute care environments, from community hospitals to large teaching hospitals and even children’s and specialty hospitals, and strictly manage the care of the hospital’s admitted patients. A hospitalist manages most medically required tasks, including admitting the patient from the ER, ordering consults by specialty physicians, ordering diagnostic testing and monitoring the patient’s progress during the inpatient stay. The hospitalist is also responsible for ensuring the patient’s timely and safe discharge to any number of locations. Often, when the hospitalist discharges the patient from an acute care setting, he or she may be the first prescriber to order home medical equipment for the patient. There are many reasons why the hospitalist needs to order HME, but this can lead to trouble. Once a patient steps out of the hospital doors, a hospitalist is no longer involved in his or her care. As a result, hospitalists have become wary of signing HME orders for these patients they will not follow. They are concerned that, under current requirements, they will be held accountable for fraud or for patient nonuse. For the last five or six years, suppliers have had the added burden of the increasing scope of Medicare audits and the requirement of complete prescriber documentation. Suppliers struggle to educate the hospital case managers and discharge planners about the documentation needed from the prescribers (such as the hospitalist) before accepting orders, all while focusing on the quality—and not quantity—of accepted referrals. So what does a supplier do when a hospitalist will not sign an order? Since July 1, 2013, the only answer is to not take the order. Under WOPD requirements, referrals simply cannot be taken without compete written, detailed, signed orders, and there is no assurance that a community physician, who may be seeing the patient for the first time, will provide signed orders for items he or she isn’t prescribing. What can you do? Work with your prescribers. Contact the medical staff office of the hospital or whatever department hires and manages hospitalists. Make an appointment with the department supervisor and describe your situation—they may not be aware of the problem. Reassure the hospitalists and their supervisors that, despite what Medicare tells them, they will not be held accountable, because their discharge orders always include for the patient to “follow up with their community physician within X days,” and that will be sufficient to cover them after discharge. No matter what troubles you may be experiencing, you cannot work without orders prior to delivery, whether you submit for payment or not. Lack of orders is a high-level accreditation deficiency that could close your doors. Discuss the Medicare DME requirements with hospital staff, and work with them to enforce these regulations. The hospitalist should sign orders if he or she prescribes the item(s). Medical staff contracts usually turn over at the end of June each year, with new staff starting on July 1—the same schedule as interns and residents who begin on that date. Take the time now to get your prescribers educated and plan repeat education for new staff in July. Your offer may be just what your hospitals need as they struggle to provide as much information as possible to new staff. But, at the very least, it should help alleviate any troubles you may not have to experience with getting signed orders.