Non-compliance in healthcare typically means a patient who intentionally refuses to take prescribed medication or does not follow treatment recommendations. This term is often used in medical documentation as physicians and/or care team professionals categorizing patients in the ‘not doing what I say’ category. The effects of this term project’s a picture of intentional negligence by the patient, placing blame on their choices. Non-compliance was once a more popular term used in the medical community to remove perceived risk from the provider, however, recent research has created a different picture. According to research from Sous, W., Frank, K., Cronkright, P. et al. (2022), the term ‘non-compliant’ has been shown to compromise care, particularly for marginalized communities. Ethically, this term has failed to demonstrate a provider’s respect for patient autonomy and has created a reverse effect of the ‘do no harm’ mantra.
So, let’s give a hypothetical example, Mr. Jones has been placed under observation services at the local hospital for evaluation of his chest pain. Mr. Jones lives alone about 20 miles from the hospital where he is seeking care. While working outside, he started having shortness of breath and chest pain leading him to call 911. At the hospital, the care team starts running numerous tests on Mr. Jones, but all he can think about is his land and his animals back home. Mr. Jones is concerned about his heart but was just hoping for some medication and to be back on his way. He really doesn’t like doctors’ offices, much less hospitals and has spent many years avoiding them. When the physicians come in the room, they tell him what they are doing using hard to understand medical terminology. The nursing staff have been giving him medications and hooking him up to machines again with confusing medical terms. Mr. Jones has now been at the hospital overnight and although he is feeling better, he does not see the need to stay. He has his animals at home that need to be fed and he wants to take care of his property. Mr. Jones requests to leave. At this point all efforts kick in from the hospital as they term Mr. Jones as wanting to leave against medical advance, AKA, the AMA discharge and document his behaviors as non-compliant in the medical record. Rather than diving into the misconception of the AMA discharge and Mr. Jones concerns. I will say that Mr. Jones agrees to help with his discharge and get the information he needs for follow-up care and the care team even helps coordinate a ride home. However, the labeling in his record stands, he is a ‘non-compliant patient with an AMA discharge’.
The scenario creates the picture that our lives are filled with competing priorities and stressors. With the best of intentions, the non-compliant patient does not take their medication because they do not have the money to do so. The non-compliant patient misses their doctor’s appointment because they have no transportation or maybe the city bus was late. As a healthcare community, rather than labeling our patients based on our own perspective of privilege we should use the situation to ignite a call to action that we may have overlooked a valuable piece in our patient’s healthcare needs. What if instead of just assuming the patient is simply not following medical advice or making their medical care a priority, we consider the following.
I would imagine in our lives at one point or another we all could be labeled as non-compliant and in the busy schedule and demands on our healthcare system sometimes it is easier to write ‘non-compliant’ then figure out the reasons why. However, this impacts access to care and healthcare outcomes for our patients.
References:
Sous, W., Frank, K., Cronkright, P. et al. Use of a simulated patient case and structured debrief to explore trainee responses to a “non-compliant patient”. BMC Med Educ 22, 842 (2022). https://doi.org/10.1186/s12909-022-03894-7
While underdosing is no longer a new concept in coding it remains a common area of confusion. Underdosing is when a patient takes less of
You have heard Dr. Ronald Hirsch, and I present on CMS-4204-F which introduces a process for expedited determinations for traditional Medicare beneficiaries who are reclassified
Please log in to your account to comment on this article.
Join Beth Wolf, MD, CPC, CCDS, for an in-depth webcast on the FY2025 spinal fusion MS-DRG updates. Discover key changes in DRG classification, understand impacts on documentation and CMI, and learn strategies to ensure compliance.
Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.
Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
Enhancing outpatient clinical documentation is crucial for maintaining accuracy, compliance, and proper reimbursement in today’s complex healthcare environment. This webcast, presented by industry expert Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, will provide you with actionable strategies to tackle complex challenges in outpatient documentation. You’ll learn how to craft detailed clinical narratives, utilize advanced EHR features, and implement accurate risk adjustment and HCC coding. The session also covers essential regulatory updates to keep your documentation practices compliant. Join us to gain the tools you need to improve documentation quality, support better patient care, and ensure financial integrity.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks. Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.
Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.
During this RACmonitor webcast Dr. Ronald Hirsch spotlights the areas of the OIG’s Work Plan and the findings of their most recent audits that impact utilization review, case management, and audit staff. He also provides his common-sense interpretation of the prevailing regulations related to those target issues. You’ll walk away better equipped with strategies to put in place immediately to reduce your risk of paybacks, increased scrutiny, and criminal penalties.
Copyright © 2024 ICD10monitor. Powered by MedLearn Media.
Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more
Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
