Offering Choice when No Choice is Needed

I have written several times about patient choice. We all know the rules: offer choice to patients for all post-acute services. They are part of the hospital discharge planning conditions of participation at 42 CFR 482.43, and compliance with these conditions is not optional.

Well, I recently saw my doctor, who is an employee of a regional health system. And as with many health systems, they have an electronic heath record (EHR) with a patient portal. As my appointment approached, I received an email inviting me to pre-register for the visit. As expected, the first question was about who would be paying the bill, but it also asked me to confirm my medications, health conditions, and emergency contacts. And then it asked me to sign the consent for treatment. And like every patient, I read every single word and asked my lawyer to review it before I signed.

Oh wait, I did not do that; I simply “signed it” by clicking a box. But later I did look at it more closely, and was surprised to see that my signature meant that I agreed I understood that I have the freedom to choose and select my own home healthcare provider, acknowledging that a list of providers could be furnished by registration.

What the heck? First, I am visiting my doctor in the office, and not being admitted to the hospital. Sure, home care services can be ordered on patients seen in the office. But patients can also be admitted to a nursing home or acute rehabilitation center from the office, so why was choice of Skilled Nursing Facility (SNF) or Inpatient Rehabilitation Facility (IRF) or Durable Medical Equipment (DME) or therapy provider not addressed?

And then, is choice even needed for services ordered for patients seen in the office, even if the physician is employed by a health system? Well, Section 1802 of the Social Security Act does mandate that patients have free choice of any provider, but there is not one word about requiring providers to offer a choice or provide a list or get a signature in the ambulatory setting, as opposed to the hospital. In fact, last year my physician referred me to cardiac rehab, and I was never offered choice of providers.

The other point is that a signature on a piece of paper stating that choice was offered is not required, even in the hospital. Rather, your policy must state that you are offered choice, and how you go about generating the list, but there is no requirement in the regulations for that signature. It’s the process that counts, not the proof.

Now, if your outpatient registration consent form has something like this, or you are asking hospital patients to sign a choice form, should you stop getting it signed? Absolutely not. There are lots of things we do that are not required by Medicare rules, but were instituted for another reason: to satisfy a local regulation or a mandate by an accreditation organization, or perhaps in response to an adverse outcome, either medically or legally. You certainly can try to ascertain the origin of the requirement so you better understand it, but follow your process and chain of command.

On the other hand, if you are like my doctor’s health system and asking patients to acknowledge something that never happened, then absolutely, speak up. Remember, when surveyors do arrive to assess your compliance with the Conditions of Participation, they will be meeting patients and asking them if they were offered choice – whether or not there is a signed document stating that choice was offered. And the patient’s perception of being offered choice is what really matters.

Opinions expressed are those of the author and not that of R1 RCM or MedLearn Media.