CMS Audits as Safeguards Against Fraudulent Order Entry

In the continuing discussion about computerized provider order entry (CPOE), a frequent question concerns whether a noncredentialed health care professional could circumvent any safeguards and perform order entry into an electronic health record (EHR) system. As Rob Antony of CMS stated last year, it is indeed possible to do this. However, that possibility is one of the primary reasons for CMS audits, which could identify and penalize such behaviors. A standard EHR system would maintain a log of which staff members enter orders. Any practice found violating the requirements for order entry could be subject to financial penalties. The full text and video of Mr. Anthony’s statement follows:

“There’s not a requirement as part of certification that your certified EHR has to identify you as [a] credentialed [medical assistant]; there’s actually not a requirement within certification that you have to be identified as anything. However, for purposes of entry, for purposes of workflow, the [eligible professional] and the practice [have] to make sure that’s who is entering that information. We realize that not every EHR may have that information, but certainly a large number of them do, and I can anticipate that an auditor would ask for that log.”

***

“We don’t actually have any additional regulatory authority beyond what we have with incentive payments and payment adjustments, specific to this program for CPOE. It is possible for anyone to game the system here. That’s why an auditor might look at credentialing and would look at those audit logs to see whether or not that was likely to have happened. The authority here, or the clout, Is either if an auditor goes through and discovers that people were erroneously counted within a numerator and you did not actually meet meaningful use, you would forfeit an incentive payment, and then potentially [it would] be applied [to] the payment adjustments. So certainly if an auditor comes by afterward and discovered that your attestation was not correct, then it would be a forfeit of payment or a recoup of payment, and potentially things that are egregious fraud get sent for additional prosecution.”

About Donald A. Balasa

Donald A. Balasa, JD, MBA, chief executive officer and legal counsel for the American Association of Medical Assistants, keeps his eye on what is happening in the profession.
This entry was posted in Certification and the CMA (AAMA) Credential, On the Job, Professional Identity, Scope of Practice and tagged , , , , , , , , , . Bookmark the permalink.

12 Responses to CMS Audits as Safeguards Against Fraudulent Order Entry

  1. Would someone with an EMT be considered appropriately credentialed for the purposes of MU?

    • Thank you for your question. Because there are different levels of EMTs under the various state laws, and the amount of education also varies, it is my legal opinion that the following CMS FAQ would control:

      [EHR Incentive Programs] When meeting the meaningful use measure for computerized provider order entry (CPOE) in the Electronic Health Records (EHR) Incentive Programs, does an individual need to have the job title of medical assistant in order to use the CPOE function of Certified EHR Technology (CEHRT) for the entry to count toward the measure, or can they have other titles as long as their job functions are those of medical assistants?
      If a staff member of the eligible provider is appropriately credentialed and performs similar assistive services as a medical assistant but carries a more specific title due to either specialization of their duties or to the specialty of the medical professional they assist, he or she can use the CPOE function of CEHRT and have it count towards the measure. This determination must be made by the eligible provider based on individual workflow and the duties performed by the staff member in question. Whether a staff member carries the title of medical assistant or another job title, he or she must be credentialed to perform the medical assistant services by an organization other than the employing organization. Also, each provider must evaluate his or her own ordering workflow, including the use of CPOE, to ensure compliance with all applicable federal, state, and local law and professional guidelines.

      Created: 08/20/2013

      (FAQ9058)

      I hope this is helpful.

      Donald A. Balasa, JD, MBA
      Executive Director, Legal Counsel

      American Association of Medical Assistants
      Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org

      Visit us on Facebook! http://www.aama-ntl.org/facebook

      The CMA (AAMA): Health Care’s Most Versatile Professional

  2. Maggie says:

    What exactly is the definition of order entry? In our office MA’s all exectute orders written by the providers with the exception of weight checks and allergy testing. I am just trying to understand what your definition of order entry is.

    • Thank you for your question. The CMS rule states that order entry consists of entering medication, laboratory, or radiology orders into the CPOE system. The question of which orders can be entered into the CPOE system and have such entry count toward meaningful use is different from the question of which physician orders medical assistants are permitted to execute.

      I hope this is helpful.

      Donald A. Balasa, JD, MBA
      Executive Director, Legal Counsel

      American Association of Medical Assistants
      Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org

      Visit us on Facebook! http://www.aama-ntl.org/facebook

      The CMA (AAMA): Health Care’s Most Versatile Professional

  3. Cindy says:

    The word I have heard in our office about “licensed healthcare professionals ” is that licensed medication aides can put in CPOE for stage 2 meaningful use because they are “licensed professionals “, does that sound correct ?
    Ty

    • Thank you for your question. Note the following CMS FAQ:
      [EHR Incentive Programs] When meeting the meaningful use measure for computerized provider order entry (CPOE) in the Electronic Health Records (EHR) Incentive Programs, does an individual need to have the job title of medical assistant in order to use the CPOE function of Certified EHR Technology (CEHRT) for the entry to count toward the measure, or can they have other titles as long as their job functions are those of medical assistants?
      If a staff member of the eligible provider is appropriately credentialed and performs similar assistive services as a medical assistant but carries a more specific title due to either specialization of their duties or to the specialty of the medical professional they assist, he or she can use the CPOE function of CEHRT and have it count towards the measure. This determination must be made by the eligible provider based on individual workflow and the duties performed by the staff member in question. Whether a staff member carries the title of medical assistant or another job title, he or she must be credentialed to perform the medical assistant services by an organization other than the employing organization. Also, each provider must evaluate his or her own ordering workflow, including the use of CPOE, to ensure compliance with all applicable federal, state, and local law and professional guidelines. Created: 08/20/2013 (FAQ9058)

      Medication aides, in some states, are indeed required by law to be credentialed. However, the question is whether they are “appropriately credentialed to perform medical assistant services.” In my opinion, the language of the CMS rule and of the above FAQ does not resolve this question. It is up to each employer to determine whether the medication aide is indeed competent and knowledgeable in electronic order entry. If the medication aide is, then it appears that the medication aide is permitted to enter orders and have such entry count toward meaningful use.

      I hope this is helpful.

      Donald A. Balasa, JD, MBA
      Executive Director, Legal Counsel

      American Association of Medical Assistants
      Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org

      Visit us on Facebook! http://www.aama-ntl.org/facebook

      The CMA (AAMA): Health Care’s Most Versatile Professional

  4. Carrie Howarth says:

    The state of Florida statutes regarding medical assistants only list the AAMA and AMT credentials as “Certified”. Does this mean anything in regards to which credentials meet order entry requirements for CMS? Or is “credentialed” different than “certified”?

    • Thank you for your question. Note the following language in the Florida law:
      (3) CERTIFICATION.—Medical assistants may be certified by the American Association of Medical Assistants or as a Registered Medical Assistant by the American Medical Technologists.

      The law does not state that medical assistants MUST BE certified by the AAMA or have the RMA(AMT).

      The language of the Florida law has no bearing on which medical assistants CMS considers as “credentialed,” and therefore able to enters orders into the CPOE system for meaningful use. Note the following from CMS:
      Q: In order to meet the objective for computerized order entry (CPOE) for the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs, do medical assistants need a specific kind of credential from a specific organization to be considered credentialed and therefore able to enter orders using CPOE that can count in the numerator of the measure?

      A: A credentialed medical assistant is a medical assistant who has received credentials or otherwise been certified by an organization other than the employing organization to perform duties as a medical assistant. CMS does not specify credentialing organizations that would qualify medical assistants under this definition. Medical assistants who are credentialed, certified, licensed, or otherwise affirmed as medical assistants by an organization other than the one which employees them can enter orders for the purpose of this objective.
      I hope this is helpful.

      Donald A. Balasa, JD, MBA
      Executive Director, Legal Counsel

      American Association of Medical Assistants
      Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org

      Visit us on Facebook! http://www.aama-ntl.org/facebook

      The CMA (AAMA): Health Care’s Most Versatile Professional

      • Carrie Howarth says:

        Thank you, yes that was very helpful. With the new requirements to meet the CPOE objective, we’ve been working to credential anyone who can place orders in our EMR and there have been questions about what that actually means with the many credentialing agencies out there.

        Personally, I’ve proudly held the CMA (AAMA) credential for almost 20 years.

      • Excellent! You are very welcome!

        Donald A. Balasa, JD, MBA
        Executive Director, Legal Counsel

        American Association of Medical Assistants
        Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org

        Visit us on Facebook! http://www.aama-ntl.org/facebook

        The CMA (AAMA): Health Care’s Most Versatile Professional

  5. debbie says:

    If there are 2 providers and one Nurse practitioner can a medical assistant take orders from a nurse practitioner in this office? In South Carolina

    • Thank you for your question. Note the following excerpt from the South Carolina Nurse Practice Act. It does permit RNs, LPNs, and advance practice registered nurses to delegate to unlicensed allied health professionals such as medical assistants:
      Title 40 – Professions and Occupations
      CHAPTER 33.
      NURSES
      ARTICLE 1.
      NURSE PRACTICE ACT

      SECTION 40-33-42. Delegation of tasks to unlicensed assistive personnel.

      (A) An advanced practice registered nurse, registered nurse, or licensed practical nurse is responsible for the delegation and supervision of nursing tasks to unlicensed assistive personnel. Tasks that may be assigned to unlicensed assistive personnel must be stated in the employers’ policies, and the employer shall verify the training of this personnel and their competencies to perform the tasks.

      (B) Tasks which may be delegated and performed under supervision may include, but are not limited to:

      (1) meeting patients’ needs for personal hygiene;

      (2) meeting patients’ needs relating to nutrition;

      (3) meeting patients’ needs relating to ambulation;

      (4) meeting patients’ needs relating to elimination;

      (5) taking vital signs;

      (6) maintaining asepsis;

      (7) observing, recording, and reporting any of the tasks enumerated in the subsection.

      (C) Subject to the rights of licensed physicians and dentists under state law, the administration of medications is the responsibility of a licensed nurse as prescribed by the licensed physician, dentist, other authorized licensed provider or as authorized in an approved written protocol or guidelines. Unlicensed assistive personnel must not administer medications, except as otherwise provided by law.
      Note this last section. Nurses are not permitted to delegate, on their own authority, to unlicensed allied health professionals such as medical assistants the administration of medication.

      I will send to your e-mail address a statement about this from the SC Board of Nursing.

      I hope this is helpful.

      Donald A. Balasa, JD, MBA
      Executive Director, Legal Counsel

      American Association of Medical Assistants
      Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org

      Visit us on Facebook! http://www.aama-ntl.org/facebook

      The CMA (AAMA): Health Care’s Most Versatile Professional

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