eOrder given trial run
Relief may be on the way for access personnel faced with explaining to surprised and irate patients that they’ll have to pay for a test or procedure themselves because it doesn’t meet Medicare’s medical necessity requirement. A process for screening orders for medical necessity at the point of care — in the physician’s office — and electronically sending them to the hospital has been developed by Oakbrook Terrace, IL-based Nebo Systems and is planned to be piloted at Advocate Good Samaritan Hospital in Downers Grove, IL.
Eliminating conflicts
The hospital’s goal is to "eliminate unintentional conflict between diagnosis and procedure codes on outpatient physician orders prior to the delivery of service," explains Margie Winfield, RN, clinical operations assistant for ambulatory services at Advocate Good Samaritan, a 315-bed facility with a large outpatient population.
"Not all physicians are savvy about what they need to put down," she says. "They may put down the diagnosis, but maybe it’s a symptom associated with the diagnosis that they need to put down," Winfield notes.
While targeting these coding conflicts with an eye on reducing Medicare denials, the facility will measure its progress in terms of customer satisfaction, she continues. "We have physicians who are unhappy because there are so many phone calls back and forth when the order doesn’t meet medical necessity," adds Winfield. "We’re asking about what else the patient might have, but we can’t tell them what to put down. We needed a product to help them make those decisions up front," she says.
Registrars, meanwhile, are dissatisfied because they have to make all those calls to physicians who become angry, Winfield adds. "So we are very, very focused on the customer — including the physicians, their staff, and our registration staff," she explains.
The product, eOrder, is part of the vendor’s web-based practice management system, Health Nautica, but also can be used independently of that system, says Katherine H. Murphy, CHAM, patient access coordinator for Nebo. "Patient information and demographics can flow from the practice management system or be keyed into eOrder separately to create the outpatient order," she adds. "If it’s a Medicare patient, the order will be run through medical necessity screening software and then sent to eCare," Nebo’s on-line electronic verification and claims status portal (www.ecare.com). The hospital can retrieve the electronic orders from the eCare archive, Murphy notes.
Physician is able to review the file
"What this product does is allow physicians to determine whether or not the service is deemed medically necessary by Medicare," she points out.
If the procedure does not meet the Medicare criteria, "this gives the physician the opportunity to review the record and see if the patient has another medical condition that [justifies] having this particular procedure," Murphy adds. If so, that information can be added to the order, she explains, and if not, the order can be flagged so hospital staff know when they receive it that an Advance Beneficiary Notice will need to be signed by the patient before the procedure is done.
Perhaps most importantly, the physician would then have the opportunity to inform the patient of the situation, saying something like, "While Medicare does not consider this procedure medically necessary, we do consider it good practice and would like for you to have it," she explains.
Having a prescreened order at the point of service not only will avoid difficult encounters with patients, but will improve throughput in the registration area by eliminating the need to call physicians for additional information, she points out. "Payer requirements and compliance regulations change frequently," Murphy says. "The eOrder process will help manage the complexities at an earlier point in the revenue cycle."
Because the order is electronically on file, problems created when patients forget or lose their orders are eliminated," she adds. "If you need it for an audit, you’re not looking for a piece of paper floating around."
A serendipitous start
The idea behind the pilot, which was to be conducted in the offices of three physicians who practice internal medicine in a building adjacent to Advocate Good Samaritan, is to observe the electronic order work flow in a real-life situation. "We know how it is designed to work in concept, but what are the issues in a physician’s office, and what do we have to tweak to make this work?" Murphy continues.
The hospital was analyzing the process of real-time code scrubbing when the realization came that, while the hospital is ultimately accountable for coding and medical necessity issues, "if we could possibly get into physician offices [with that step], we’d be ahead of the game," Winfield says.
Part of the impetus for the development of eOrder, meanwhile, also came from a conversation Murphy — who formerly worked in finance and access at Advocate Good Samaritan — had with Shailesh Bhobe at Nebo. As they talked about the Health Nautica practice management system, "it became apparent that the one additional piece we could use was this [electronic order function]. The convenience to the patient and hospital will be phenomenal," she notes. "Many of these appointments aren’t even scheduled; they’re walk-ins," Murphy says. "It’s the ultimate associate satisfier. If the patient has already been told, it takes the pressure off the hospital. It also eliminates phone calls to busy practices."
[Editor’s note: Look for more information on the medical necessity pilot at Advocate Good Samaritan Hospital in a future issue of Hospital Access Management. Margie Winfield can be reached at (630) 275-1720. Katherine Murphy can be reached at Nebo Systems at (630) 916-8818, ext. 34.]
Relief may be on the way for access personnel faced with explaining to surprised and irate patients that theyll have to pay for a test or procedure themselves because it doesnt meet Medicares medical necessity requirement.
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