Compliance Corner – Can I bill for my time if a patient refuses?
Patty Scheets, Vice President of Quality and Compliance
We’ve all been there. We go into a patient’s room to start our therapy session, and the patient refuses. We know that from a medical point of view, the patient could benefit from our services, so we try to better understand why the patient is refusing and encourage them to participate. Sometimes, the patient agrees, and sometimes they don’t. If the patient still refuses, is the time we’ve spent with them a billable service? Here are a few bulleted notes that may help:
- We must always remember that patients have the right to refuse services.
- If a patient refuses care, we should determine if they are refusing all care or if they refusing out-of-bed activity (or other). Are they agreeable to education about their plan of care or some other intervention?
- We should document what they refused and what they agreed to do. You may only bill for services the patient agreed to.
- Assuming they are refusing out-of-bed activity, the intervention we provide must be targeted toward the patient’s goals. Best practice is to document which goal the intervention addressed.
- Assuming we provided an education intervention in these cases, document the patient’s response to education. Documenting teach back of the education makes the documentation of patient response stronger.
- Some of our patient activation and engagement strategies may be useful in these circumstances.
Finally, if this type of intervention is provided more than 1-2 times during a case, unless something has changed relative to the patient’s condition, it will be difficult to support the care as skilled.
Please let us know if you have any follow-up questions by emailing the compliance department.
REMINDER: Compliance training is coming in July! Read this Insider article for all the details.
