Payment Adjustments Emphasize the Importance of Proper Order Entry

As the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs continue to be implemented and enforced, questions arise about how certain objectives for meaningful use affect reimbursement. The short answer to these questions is that all objectives are critical. Failure to meet even one objective for meaningful use can result in not only a payment forfeiture, but also retroactive recoupment of previous payments, as well. Thus, it is incumbent on all health care providers to ensure that proper steps are being taken to comply with all meaningful use objectives. The text and video of Mr. Anthony’s statement on this matter follows:

“That’s correct. If [a practice] is not meeting all of the objectives for meaningful use for a program year, then that payment would be forfeit. … As we move forward, of course, every year is going to be a deciding year for payment adjustments—so potentially, if an audit comes through and you forfeit a payment, you may not only be forfeiting the payment, but you would also be subject retroactively to payment adjustments, as well.”

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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.”

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Clinical Decision Support Alerts and Credentialed Medical Assistants

We have detailed who can perform computerized provider order entry (CPOE) for meaningful use objectives, as well as the potential costs of improper CPOE. Naturally, the broader question in this discussion is why only licensed health care professionals or credentialed medical assistants are allowed to perform CPOE.

These rulings are made with patient protection as the primary goal. One way the limits on CPOE help ensure that protection involves a function of the CPOE system known as clinical decision support alerts.

Robert Anthony of the Centers for Medicare and Medicaid Services spoke about these alerts and their importance for patient safety in his presentation. The full text and video are below:

“The purpose of this really is to make sure that when information goes into a system, and it is done obviously prior to any action being taken on the orders … that somebody who has some clinical expertise or authority is able to see any of the clinical decision support alerts that pop up and say, ‘You may not want to prescribe this medication because of a contraindication.’ Then they can take action on that for patient safety, whereas I as a lay person might see a clinical decision alert, have no idea what that means, and ignore it completely. So that’s really the whole idea behind having a licensed health professional or a CMA (AAMA) to look at that.”

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The Cost of Improper CPOE

We have established who can perform computerized provider order entry (CPOE) for meaningful use objectives. However, what happens when someone other than a licensed health care professional or credentialed medical assistant performs CPOEand the provider counts the entry of these orders for meaningful use? Would the provider in question be penalized for such an error?

The presentation by Robert Anthony of the Centers for Medicare and Medicaid Services (CMS) helps illuminate the situation. Essentially, CMS would not levy a direct penalty against the provider, but the order in question could not be counted toward the meaningful use objective. This, in turn, could result in financial loss down the road. The text and video of Mr. Anthony’s response is below:

It’s not a penalty, but you wouldn’t be able to count those people as part of meaningful use for CPOE. … If I as a lay person go through and I complete a medication order, [CMS does not] have any jurisdiction over whether that is allowed, although there may be some local or state regulations that would cover that. As far as meaningful use is concerned, it means that you couldn’t count that order within the numerator of that particular objective. So it is possible that because of how that is calculated you might not meet that particular threshold for that objective. But it’s not a penalty that we apply for it—it’s just that you couldn’t count those orders toward the actual meaningful use objective.

As indicated in my Public Affairs article in the July/August 2013 CMA Today, an eligible professional must meet all Core Objectives. Failure to meet any one Core Objective would result in no incentive payment.

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General Entry vs. CPOE in the Electronic Health Record

As discussions about the CMS Stage 2 rule continue, one question that persists is whether non-credentialed medical assistants–and by extension, lay people–can enter orders into the electronic health record (EHR). What entries can such workers make, if any?

Robert Anthony of the CMS Health IT Initiatives Group touched on this topic during our joint presentation at last year’s AAMA Annual Conference. In short, the only meaningful use objective that carries a requirement as to who physically enters orders is computerized provider order entry (CPOE). The full text of Mr. Anthony’s response follows, with video:

For all of these objectives except computerized provider order entry, there really isn’t a requirement about who enters that information into an EHR, or who takes a particular action at all. Anybody can really do that. The only objective that there are any requirements around who does the actual entering for the EHR is that CPOE.

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There are two different processes here. One is for entering something like blood pressure, or height/weight. Anybody can do that. Absolutely anybody can do that. In fact, there are many systems that are part of larger organizations where they’re not entering that information at all;they’re actually  getting that information from another system, especially demographic information that’s being loaded from a practice management system automatically. But when it comes to CPOE, we are very specific about who enters that information. The information either has to be entered by a licensed health care professional–and has to be done prior to any action being taken on the order–or it has to be entered by a [credentialed] medical assistant. You can’t have a lay person who enters that, somebody who goes through and just clicks a button. You have to have the actual licensed health care professional or [credentialed medical assistant].

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