Commentary: Order, orders, orders

BETHESDA, Md., March 15, 2013—As we often like to remind our payers, even though we are treated and reimbursed as if we are simply an equipment rental company, we are much more than that. We are not like your neighborhood rental store where you can rent a lawnmower or tables and chairs for a party. We are part of the health care delivery system. A customer can walk through our doors and purchase a retail item for cash, but they cannot rent a legend item or bill an item to their insurance provider (when they are permitted to do that) without following the required steps, which always includes a complete written order by the prescriber. Sounds simple, but often it is not.

As much as Medicare torments our DME world with audits, competitive bidding and more, they also torture the prescribers with threats 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 the hospital who are employed full time at the hospital. They do not have private practice offices and do not see patients for visits and checkups. They strictly manage the care of the hospital’s admitted patients. They are found in community hospitals, large teaching hospitals and even children’s hospitals. Admitted patients may or may not be followed by a community physician or nurse practitioner, but while in the hospital they are managed by the hospitalist. The hospital’s process is for their hospitalist to manage many the functions, including admitting the patient into the hospital from the emergency room, or ordering consults by other specialty physicians, to monitoring the patient’s progress during the inpatient stay. The hospitalist is also responsible for the patient’s timely and complete discharge from the hospital to any number of locations, from their home to a rehabilitation facility. Oftentimes when the hospitalist discharges the patient from the acute care setting, he/she is the first prescriber to order home medical equipment for the patient. Maybe the patient now needs a hospital bed, a walker or a wheelchair. Maybe they are now going to have to use oxygen for the rest of their life. There are multiple situations where the hospitalist has to discharge a patient and prescribe DME.

But here’s where our trouble occurs. The hospitalist is never going to see this patient on an outpatient basis. He/she is no longer involved in the patient’s care as soon as they step out of the hospital. And with all of the browbeating Medicare does to warn prescribers about signing orders for DME for patients that they do not follow, the hospitalists have become very wary—and even downright belligerent—about signing our DME orders for these patients. They are terrorized that they will be held accountable for fraud or for patient non-use of the item(s). This situation is very common, and if you are finding this problem in your community you are not alone.

For the last three to four years suppliers have had the added burden of Medicare audits and the requirement of complete prescriber documentation. Suppliers struggle with trying to educate the hospital case managers and discharge planners about the documentation we need from the prescribers before we even accept the orders, and with all of the various audits going on we now focus on quality referrals, not the quantity of referrals we accept.

The first thing your accreditor reviews in your patient records is to ensure that you have complete orders for the equipment provided and that these orders are signed by the prescriber. And with the new face-to-face requirements starting July 1 of this year, those orders need to be from the physician who had the face-to-face encounter 60 days prior to the delivery of the equipment or by the treating hospital physician.

So how does a supplier manage this somewhat complex task when a hospitalist refuses to sign the orders? There is only one way—refuse to take the referrals (while you still can). It sounds drastic, but you cannot afford to take referrals that you will never have signed orders for and you cannot expect a community physician, who may be seeing the patient for the first time, to sign orders for items he/she did not prescribe.

Contact the medical staff office for the hospital, the department who may hire and manage the hospitalists, or if they do not, find out who does. Make an appointment with the hospitalist’s supervisors and describe your situation, because they may not be aware of the problem. Reassure the hospitalists that they include in their discharge orders for the patient to follow-up with their community physician,” within X number of days” and that will “cover” them after discharge.

With all of the challenges hospitals are facing, they certainly do not want patients languishing in unbillable beds awaiting discharge. Discuss with them the Medicare DME requirements and work with them to enforce these regulations with their staff. The hospitalist is the correct one who should be signing these orders if he/she prescribed the item(s) and although Medicare may scare them, in this case, they are responsible.

Your accreditor may listen to the problems you are experiencing with hospitalists, and although you might not even be billing for items when you don’t have signed orders, it will not matter. You cannot work without orders when they are required. Not having orders is a high level accreditation deficiency—whether or not you ultimately bill for the item—that could close your doors. These referrals are not worth that difficulty, especially with all of the other issues we have to face. If you won contracts in competitive bidding, educate your hospitals now and make sure everyone understands all of the requirements and expectations before the program begins and before things could get quickly out of hand.

About the author: Mary Ellen Conway, RN, BSN, is president of Capitol Healthcare Group, LLC in Bethesda, Md., which provides health-care management expertise in accreditation preparation and survey follow-up, operations assistance, design of quality improvement programs and outcomes measures. She can be reached at 301-896-0193 or www.capitalhealthcaregroup.com.