Medical Compliance Services Tips of the Month
Importance of Physician’s Orders
Physician’s orders provide directions to the healthcare team regarding medications, procedures, treatments, therapy, diagnostic tests, laboratory tests, and nutrition. The order establishes medical necessity for the services provided, which in turn supports the payment. All tests, procedures and medications require a physician’s order.
A physician’s order needs to be legible, signed, dated and timed.
Joint Commission guidelines help to regulate the use of scribes:
• Verbal orders may neither be given to nor by scribes.
• Signing (including name and title) and dating of all entries into the medical record is necessary—for both electronic or manual documentation (RC.01.01.01 and RC. 01.02.01). For those organizations that use Joint Commission accreditation for deemed status purposes, the timing of entries is also required. The role and signature of the scribe must be clearly identifiable and distinguishable from that of the physician or licensed independent practitioner and other staff.
Example: “Scribed for Dr. [name of physician] by [name and title of scribe], [date and time of entry].” The physician must document that the note accurately reflects the work performed by him/her and authenticate it with a signature.
• Scribes must meet all information management, HIPAA, HITECH, confidentiality, and patient rights standards, just as other hospital personnel (IM.02.01.01, IM.02.01.03, IM.02.02.01, RI.01.01.01).
• Scribe policy must be provided to the scribe.
• A signed Scribe Agreement must be on file.
Clinical Research Billing Compliance
Some pitfalls to avoid when billing for services and managing funds in a clinical trial:
Double Billing or “Double Dipping” – if a claim is submitted to and paid by a third-party payer or Medicare and the sponsor reimburses for all or some of the same service, this is considered double dipping and may constitute fraud.
Waiving co-payments and offering free services to volunteers in clinical trials is a violation of government regulations. http://oig.hhs.gov/fraud/docs/alertsandbulletins/SABGiftsandInducements.pdf
More Billing Compliance Tips can be found at www.obc.med.miami.edu.