Question: Right now, we have a room rate which is $499.00 higher than our regular inpatient bed. This charge is added when a RN begins isolation protocol. All other accommodation changes are done by physician order only. I have asked the question if this is okay if there is no physician order, as I worry about what will happen if we’re audited. I told nursing they could do the isolation, but I’m worried about charging the patients a higher room rate without a physician order. What is your take on this?

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Answer: My take on it is multi-faceted. The main thing to think about overall is that, on inpatients, the hospital gets paid by DRG. Therefore, there’s no real benefit in charging more for a particular type of room if the diagnosis isn’t going to support it on the back end. Room charges only help cover costs, which are reported to Medicare for the cost report later on, and that’s it.

Now, overstating costs is dangerous, which means that charging for something that wasn’t deemed medically necessary on a consistent basis so that you can drive your costs up, can be considered fraudulent. If it’s something that happens from time to time, on a judgment call, it’s no big deal.

I gave all that information first to come back to this. The type of bed a patient is put into is supposed to be based on medical need, except if a patient requests a private room, in which case the hospital can charge more, but the difference must be billed to the patient. If a patient is moved to isolation, ICU, vent, etc, they’re supposed to be moved because of medical necessity.

Medical necessity is supposed to be determined by a physician, period. There are times, in an emergency, when a nurse might have to make a quick call, but it’s supposed to be backed up by a physician, and it all has to be documented as to the reason why. Putting someone through the paces and not actually moving them to an isolation room would be considered fraud; can’t do it.

Moving them to an isolation room without a physician signing off on it is risky, if it’s done often, because it will distort the statistics on the cost report. If it’s a rare event, you could probably get away with it.

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