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By Phoebe Moore, BA, CPC, CPC-H July 2003 20 Editor’s note: Phoebe Moore is a Project Manager and Senior Consultant with HP3’s Coding and Audit Group. In her role, she conducts onsite medical record reviews, mentoring, and coding training programs. She has managed pre-billing and concurrent coding audits and conducted coding in-service education for both coding staff and physicians. She may be reached at 610/332-2990. Physician practices are often confronted with the difficult circumstance of dealing with a patient who fails to show up for a scheduled appointment. Missed appointments cost the practice money. Particularly for small practices, appropriate staffing and scheduling are critical to ensure a profitable enterprise. Practices may feel compelled to develop a policy to charge patients for these missed appointments. What are the options and how can we implement such a policy? Does Medicare permit this? If patients are charged will the monetary benefits outweigh the risk of losing the patient to a more flexible practice? A Medicare provider may bill a beneficiary for a missed appointment. However, Medicare does not provide any type of benefit for missed appointments. Thus, the charge for this missed appointment would be considered a non-covered service and is therefore the responsibility of the patient. Several important steps must be taken so that the practice is certain that the policy is clearly understood and applied without discrimination. First, patients should be notified in advance. A written no-show policy should be provided to all new patients. Established patients should receive a notice by mail including information about fees, the number of hours in advance when cancellations will be accepted, and any exceptions to the policy. The policy should be posted in the office or clinic so that patients are reminded of the consequences of missing a scheduled appointment. The policy must be standard and must apply to all patients equally. It would be inappropriate to exclude any particular group of patients based upon the type of insurance coverage, as this could be viewed as discriminatory. Prior to standardizing the policy, all managed care plans should be reviewed. Some providers’ contracts may contain restrictions prohibiting the provider from charging for an appointment that is not kept. If this is the case, then the policy could not be applied equally to all patients. The approach to billing patients for missed appointments is a matter of personal choice. The ramifications may be significant and should be carefully considered. Patients may be offended by such a policy or may decide to leave the practice. Before implementing a charge for the no-show visit it may be wise to consider a less drastic approach. If the true intention is preventive as opposed to punitive, then there are other options. One suggestion is to call the patients a PHOEBE MOORE day or two before the scheduled appoint with a reminder, confirming the date and time. It is easy for patients to forget appointments that have been scheduled weeks and months in advance. If the patient has a conflict at the time of the call and needs to cancel, there may still be an opportunity for the practice to fill the open appointment. This method allows the practice to accommodate emergencies and urgent cases as well as promoting a positive, caring relationship with the patient. Patients who have missed previous appointments may be scheduled at the end of the day to avoid inconveniencing the physician and staff in case the situation occurs again. For habitual “no show” offenders, it may be necessary to legally terminate the physician-patient relationship. In this case, the following steps should be taken: ■ A 30-day notice in writing via certified mail should be sent to the patient. ■ A return receipt should be requested and kept on file. ■ The notice should include an explanation of the reason for the termination. ■ The practice should assist the patient
in locating another physician. ■ The practice should offer to transfer medical records to the new physician. ■ The practice should continue to provide care if the patient is sick. The physician-patient relationship is a complex one. It is both a personal relationship and a business arrangement. Physicians often spend years of hard work and hours of communication to establish the trust and confidence of their patients. For this reason physicians may try to divorce themselves from the business aspects of the practice, such as collecting money, discussing fees, and explaining policies. Office administrators and practice managers may need to account for a drop in revenue or a decrease in the number of patient visits. A no-show policy may seem like a reasonable solution. But policies and procedures that appear to be inflexible or insensitive can damage one of the office’s most valuable yet intangible assets; the patient’s perception of the office. Patients need to feel that they will receive quality care in a sensitive and compassionate atmosphere. It would be wise to consider all alternatives and to seriously weigh the possible outcomes of implementing a no-show policy. A policy which is initially developed to resolve a financial concern might ultimately cause the opposite to occur. ■ SAVE THE DATE! AHLA/HCCA Fraud and Compliance Forum September 21-23, 2003 Washington, DC For more information, call: 888/580-8373 By Joseph J. Russo, Esq. Editor’s note: Joseph J. Russo, Esq., is ■ Allegations of “under documentation” or “insufficient documenta- President, HP3 Inc., which is located in Bethlehem, PA. He may be reached at tion” 610/882-2200. ■ Claims of medically unnecessary services being provided Compliance and Health ■ Poor continuity of patient care Information Management ■ An impact on quality of patient care professionals often tell stories overall about attending physicians who have handwriting that is difficult to understand. Poor handwriting results in illeg- often review medical charts to ensure Medicare carriers and intermediaries ible documentation creating liability that the documentation is consistent and risk issues for hospitals and physicians. These include False Claims Act audits and medical chart reviews are with the reimbursement received. The issues, quality assurance issues, risk performed by medical record professional and/or clinicians. These auditors management issues, JCAHO accreditation issues, increased audit potential will not spend an inordinate amount of from public and private payers, as well time attempting to decipher the handwriting of the attending physician. as medical malpractice risks. In addition, illegible documentation can have a When handwriting is illegible, the auditor will not give any credit to that por- direct negative impact on patient care resulting in improper medical treatment tion of the documentation. Although or the dispensing of the wrong medication. the illegible documentation creates a the service was legitimately provided, substantial legal risk. Illegible documentation is of no value in verifying More specifically, illegibility can lead to: ■ Improper treatment of the patient medical necessity or coding accuracy ■ Negligence on the part of the physician and the health care organization Manual, DOC-1, “Documentation of for services billed. (Medicare Policy ■ Medical malpractice on the part of Services”, Para. 2, Rev. 3/97.) the physician and the health care organization In addition to issues of illegible documentation and their impact on reim- ■ Dispensing of wrong medications ■ The assumption that the service was bursement, JCAHO Hospital not provided Accreditation Standards also address ■ High error rates in documentation issues of medical record legibility. and coding audits Indeed, IM.7.10.1 states that the review ■ No payment for services provided Continued on page 22 21 July 2003
Page 1 and 2: Volume Five Number Seven July 2003
Page 3 and 4: NewsFlash HCCA’s call for nominat
Page 5 and 6: the hospital and apparently approve
Page 7 and 8: COMPLIANCE FOCUS GROUP ACADEMIC/ RE
Page 9 and 10: COMPLIANCE FOCUS GROUP HOME CARE CM
Page 11 and 12: COMPLIANCE FOCUS GROUP PAYOR/ MANAG
Page 13 and 14: pleted annually? More frequently? P
Page 15 and 16: would you tell me how many staff do
Page 17 and 18: By Frank Sheeder Frank Sheeder is a
Page 19: e prudent for compliance officers a
Page 23 and 24: a tremendous amount of understandin
Page 25: Editor: Margaret R. Dragon, Directo

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