During a short-stay review, the quality improvement organization (QIO) found only a resident’s signature on some admission orders at a Franciscan Health hospital in Chicago. Although the attending physician wrote the progress notes and tracked the patients, there was no electronic co-signature before discharge, which is reason enough for Medicare to deny the claim. Rather than do a follow-up audit, however, the QIO, KEPRO, accepted Franciscan’s corrective action plan and moved on, says Ven Mothkur, M.D., corporate physician adviser for Franciscan Health in Illinois and Indiana. The chief medical infomatics officer put a feature in the electronic health record (EHR) system at Franciscan’s 14 hospitals that prevents discharges until admission orders are co-signed by attending physicians, Mothkur says. “An alert pops up.”
Admission orders written by clinicians without admitting privileges is one area of possible noncompliance in an area that has generally improved, largely because of functions built into EHRs and more familiarity with the two-midnight rule, experts say. However, hospitals still could have overpayments stemming from deficient admission orders from the years before improvements took hold.
“People are more aware of the two-midnight rule and the order requirements,” says Leslie Slater, a specialist leader with Deloitte Advisory. Discharges in 2017 are showing fewer potentially at-risk orders. “But reviews can go back six years, when people were still building their electronic health records and they’re still susceptible to these audits,” she says, including QIO short-stay audits and the HHS Office of Inspector General’s Medicare compliance reviews.
Noncompliant orders fall through the cracks. That’s the case with inpatient admission orders by clinicians without admitting privileges. Verbal orders may be placed by nonphysician practitioners (NPPs), residents or emergency room physicians, but if they don’t have admission privileges, the attending physician responsible for the direct care of the patient must sign admission orders before discharge, Slater says. The NPP, ER doctor or resident may write “bridging orders” from the ER to the admitting physicians, but they still have to be authenticated.
