Is there a better way to comply with Medicare’s medical necessity rules?

"How are other hospitals complying with the Medicare medical necessity guidelines?" asks Tammy Cieplowski, director of admitting at Beaufort (SC) Memorial Hospital. "Right now at our hospital, admitting is screening for medical necessity prior to the patient having the service; but I want to know if we’re doing it the best way. Has somebody found a better way?"

Beaufort Memorial went live in April with Boston-based Iatric Systems’ medical necessity screening software, Cieplowski says, but there are still problems with the process.

"For example, if the patient is having a CAT scan, which can be with contrast’ or without contrast;’ admitters can’t order the test, so the radiology technicians order it — they know the level of the test," she explains.

If the test fails medical necessity, the technician prints a hospital issue notice of non-payment (HINN) for the admitting department, and the admitter retrieves it and walks over to the radiology department to have the patient sign it, Cieplowski adds.

Logistically, this chain of events is less than desirable, she says, but the alternative would be to have the technicians get the HINN signed, something Cieplowski is reluctant to do. "I’m concerned about having a tech perform a financial function," she notes. "Do you want a caregiver giving financial data to a patient?"

Cieplowski also wants to know how her colleagues are dealing with "canceled preops" — cases whereby a patient comes in for a preoperative study (chest X-ray, complete blood count (CBC) and EKG), and then the scheduled surgery is canceled, perhaps because of an abnormality on the EKG. Procedures that had been preoperative tests not subject to screening for medical necessity revert to outpatient procedures that have to be screened. "How are others handling this?" she asks.

Where do you draw the line?’

And what about emergency department (ED) scenarios? "You’re registering the patient, and the doctor wants a CT for headaches. The patient may be critical. Where do you draw the line with severity of illness?" she asks. "Do you tell [a critically ill patient] they may be responsible for $600 to $700 worth of tests?"

[Editor’s note: If you have a solution to Cieplowski’s problem, please call Hospital Access Management Editor Lila Moore at (404) 636-9264 or send e-mail responses to Cieplowski can be reached at Beaufort Memorial Hospital, P.O. Box 1068, Beaufort, SC 29901. Telephone: (843) 522-5110.]