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All Things HIT

Jun 28 2013   3:43PM GMT

Physician have an “ABN” dilemma during CPOE

Posted by: AllinHIT
ABN's, CPOE, Uncategorized

Computer physician order entry (CPOE), central to the meaningful use incentives, presents an interesting dilemma to physicians delivering services to Medicare patients. At the point of care, physicians using an an EHR approved by the ONC-Authorized Testing and Certification Bodies can automatically receive an advance beneficiary notice (ABN) when placing medical orders by utilizing CPOE. These ABNs are generated when the EHR communicates with the CMS’ Medicare Coverage Database (MCD), and the MCD determines that the order being placed is not covered. The ABN, appearing on the computer screen, typically gives two options to the physician. First, the physician can print the ABN, have the patient sign it as a promissory note, agreeing to pay for the services out of pocket.  The second option, is for the physician to associate the services with a different diagnosis code. Hence, the patient will not incur the cost, and the physician is able to continue with rendering the service. The ABN was originally generated because the diagnosis code did not reflect the service as necessary.

It is this second option that creates a dilemma for the physician, has an effect on revenue, and most importantly, determines the level of patient care. I understand one of the benefits of CPOE is to eliminate unnecessary tests and/or procedures, and lower the cost of care. However, a problem arises when the physician and CMS disagree with what is “medically necessary.”  Additionally, CPOE affects the revenue stream of the hospital or the clinic performing the services. If CMS will not pay for the service, and services are suspended by the physician, it could lower the amount of write-offs that would have occurred prior to implementing CPOE.  Conversely, it could increase revenue if the Medicare patient signs the ABN and does pay for the service. Most physicians, faced with the dilemma of using option one or two, will choose they second option if they feel the service is necessary. They will then find a diagnosis code which complies. This could pose some future risk, in case of Medicare audits these transactions can be exposed, scrutinized, and require re-payment to CMS.

In my role as an Epic consultant, I’ve discussed this dilemma with physicians, and I understand their perspective. They just want to focus on the patient receiving said services, anyway they can. It pains them not to deliver care they deem necessary, and allow a patient to leave their clinic. Physicians just want to practice medicine and deliver the best care possible. Being forced to address this dilemma at point of care just disrupts care. On the other hand, I understand the payer (in this case CMS) and the hospital perspective on why ABNs should be discussed with the patient. During this baby boomer age, combined with CMS’ efforts to control healthcare costs, ABNs are a necessary evil.  I guess the question is, “How can we get the physician out of the middle?”

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