On July 1, Connolly Healthcare posted this on their Approved Issues Web page:

Issue Name: Inpatient Admissions without a Physician's Inpatient Admit Order

Description: Admissions to the inpatient setting require a physician's order in order to qualify and be paid as an inpatient stay.

Provider Type Affected: Inpatient Hospital

At first glance this might seem to be an obvious audit: the order is either in the record, or it’s not. But if you think that’s all this is about, you’ve missed the point. And this point is just the tip of the proverbial iceberg.

The Need to Know

The ‘need to know’ for healthcare provider staff at all levels increases daily, perhaps even more than you imagine. (REALLY!) Let’s consider just the short list of what your staff needs to know about: medical record documentation integrity, accuracy, and specificity; the need for physician signatures; countless regulations and regulatory monitoring agencies, such as the RACs, ZPICs, MICs, MACs. And the list goes on, regardless of the provider type or site of service.

What Did the Doctor Order?

Month to month each of us who authors these articles seeks to deliver timely and relevant information to you the reader. The bulk of my article this month focuses on a case involving a single provider type, Skilled Nursing Facilities (SNFs), and a question of what a physician ordered versus what was done for the patient. The issue involved however, does NOT concern only SNFs. The issue is applicable to ALL provider types and has been affirmed and upheld by many state courts for 45 years.

45 Years Ago

A landmark case decided in 1965 was the first to enunciate the concept that “present-day hospitals, as their manner of operation plainly demonstrates, do far more than furnish facilities for treatment…” and have assumed the role, like it or not, of being ultimately responsible for arranging and coordinating total health care. In Darling v. Charleston Community Memorial Hospital, the Illinois Supreme Court decided to hold a hospital responsible when nurses attending a patient failed to either inform the attending physician about a condition that was about to become irreversible; or if the physician failed to act, to advise the hospital authorities so that appropriate action might be taken.

That is, the hospital, not the physician, was ultimately held responsible for the standard of medical care and treatment offered within the facility.

Before 1965, hospitals did not “treat” patients – only physicians did that. The Darling decision, however, showed that hospitals were seen to have evolved, and were no longer simply buildings where private physicians cared for their private patients. Since that decision, various state courts have held that a “hospital” is directly liable for failing to monitor a physician exercising staff privileges such as treating patients in the hospital.

A More Recent Case

In 2007, CMS filed a case against a skilled nursing facility (SNF) as a result of a state site survey that found some irregularities in its patient care. The SNF was fined over $300,000 because its staff did not question a physician’s orders for a drug regimen.

Are you surprised? I’m not. This particular case was about the need for a lab test to be conducted but the case could just as easily have concerned perhaps an admission status order, the specificity of some diagnosis, the interpretation of a lab test, the need (or lack of need) for some type of procedure, a patient’s discharge status… uh oh… here’s another list that goes on and on, also!

So, what does that have to do with the new issue listed above, the one that Connolly posted on July 1? Does it really matter what “Provider Type Affected” is listed there? Does the following discussion regarding a decision related to a SNF really only apply to SNFs?

Facilities Have to Get it Right, Regardless

Is it hard to see the connection? Not for me, and I hope not for you.

So with that in mind please read the following with serious regard and think about the implications for your organization. While you’re at it, think about this: when you start with the idea that facilities must monitor physician orders, it’s not exactly a huge leap to the greatly anticipated (and feared) RAC “Medically Necessary Complex Reviews” which we have already heard are right around the corner!