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Baycare Health in Clearwater, FL, has made dramatic strides in screening physician orders for medical necessity, thanks to some new software from Tampa, FL-based Omega Systems and a lot of hard work and customizing by Mary Roberts, CCS, coding manager for ambulatory care service, and other staff. (See Hospital Access Management, January 2001.)
Now, Roberts says, Baycare is looking for other ways to make use of its medical necessity software and has focused its attention on the emergency department (ED). The health system would welcome feedback from access managers at other facilities, she adds, as it attempts to develop a way to reduce ED reimbursement denials while keeping a safe distance from any potential violation of federal COBRA/EMTALA requirements.
"We can’t give Advance Beneficiary Notices (ABNs) to patients, and we don’t want to get into access of care issues," Roberts emphasizes. "We want to make sure everyone in the ED gets the care they need, whether or not they meet medical necessity. If they don’t meet it, we won’t withhold treatment."
Baycare is primarily interested in convincing ED physicians to document more thoroughly the reasons behind the orders they write for patients, she notes. "Most of the time there is a good reason for the tests they order — it’s just not documented." That lack of documentation results in the health system not being paid for tests that in fact do meet medical necessity, Roberts adds.
"In the past, a patient would come in with head trauma, and the physician would put that down and order a CAT scan of the head," she explains. "Now [in order to meet medical necessity], the physician must document his or her thought processes. Maybe the person is dizzy and that’s why the physician thinks the test is needed. Before, they didn’t have to put that."
As a first step, Baycare has put an article in the medical staff newsletter, asking that physicians document the reasons behind their orders for radiology procedures, Roberts says. "We ask them to put [dizziness’ or whatever the reason for the test might be] in the requisition sheet that goes to radiology."
A proposal under consideration, she notes, is that the radiology technician who receives an order will check to see if it meets medical necessity, using the Omega software. If it does not, Roberts adds, the clerk will go back to the physician and ask, "Why do you think the patient needs a CAT scan?"
This will happen, she explains, in the same way that technicians currently call to clarify whether, for example, the physician wants a complete series of X-rays. "We’re not going to be telling them what should be on [the order]," Roberts says. "We won’t get into a situation where we’re leading the physicians.
"We’re not sure how this will work," she emphasizes. "We don’t know how the physicians will feel about talking to the technician about additional documentation." The plan likely will be tried first on nonurgent patients, Roberts notes.
"These are our preliminary thoughts," she adds, "on how to use this product that we already have on our computers. How can we move it into an emergency setting without compromising our care?"
[If you have feedback on the idea of using medical necessity software in the ED, please contact Lila Moore at (520) 299-8730 or firstname.lastname@example.org.]