QUALITY RELATED TO PHYSICIAN SERVICES Judy A. Coy.
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Transcript of QUALITY RELATED TO PHYSICIAN SERVICES Judy A. Coy.
QUALITY RELATED TO PHYSICIAN SERVICES Judy A. Coy
Unnecessary Services Land Surgeon in Jail Massachusetts orthopedic surgeon’s license
suspended, was convicted on 13 counts of Medicaid fraud and sentenced to six months in jail and fined $50,000
Subjected 19 Medicaid patients to 710 unnecessary x-rays and 1100 unnecessary “trigger point” injections over a two year period
History of Questionable Physician Practice Surgeon made three malpractice payments
in past 10 years and has four suits pending; never disciplined by hospital or board
Attorney General cites conviction as example of “quality of care issue” that the government will prosecute as health care fraud
Objectives of Presentation
Discuss issues related to physician quality of care
Provide strategies to maximize quality performance by medical staff
Provide resources from which to develop audit criteria to determine the quality of care provided
Strategies to Maximize Quality Performance To maximize the quality of your
compliance program, you first need to maximize the quality of care given by your medical staff
How is this possible?
Credential New Medical Staff Members Interview new medical staff well
– Use set of standardized questions for all candidates
– Ask candidate to explain gaps in education, frequent moves/job changes
– Make no exceptions to your credentialing policy – Inform candidate of incomplete status of
application/process
Perform Background Checks
Conduct reasonable and prudent background investigation – Reference and background check– National Practitioner Data Bank
www.npdb.com– Cumulative Sanction Report www.os.dhhs.gov/progorg/oig/cumsan/index.htm– General Services Administration list of
debarred contractors, if applicablehttp://epls.arent.gov
Re-credential Current Providers
Remember the OB/GYN doctor who carved his initials into his patient’s abdomen?
Physician permanently surrendered license, was indicted on assault charges
Hospital neglected to report incident to state authorities
Results of Not Reporting Incident Hospital had to submit full plan of
correction – Hired independent consulting group to analyze
management and oversight of OB/GYN department
– Provided detailed report of problems with suggested solutions within 90 days
Results of Not Reporting Incident Selected consultant also had to complete a
hospital-wide study of the facility’s quality assurance and credentialing programs
Lessons to be learned– Re-credential medical staff at set intervals– Tie compliance to credentialing process
Lessons Learned
– Solicit feedback at set intervals from existing hospital committees regarding medical staff members’ performance
– Report incidents to state authorities, as required– Create separate Credentialing Committee with
defined role– Review, revise credentialing/re-credentialing
policy/procedure, as needed
Strategies to Put Quality in Your Compliance Program Follow your institution’s credentialing and
re-credentialing procedures/policies Perform data analysis of each physician’s
practice pattern at set intervals (at least yearly) to determine physicians who are outliers (outside the norm) in their billing practices
Audit the providers’ records who are outliers; look for patterns of “assembly line services”
Strategies
Educate the providers/billing and coding staff regarding your audit findings
Determine which services are targeted for review by payors/OIG - from Carrier newsletters/OIG Annual Work Plan; focus internal audits on these services
Revise/write policies and procedures to correct any irregularities noted
Strategies
If requested to provide records by payors, set up a procedure to track all requests
Analyze the payment/non payment of the claims/services for the requested records
Perform more extensive reviews of denied services for all physicians performing those services
Educate physicians/coding and billing staff regarding results of payor/your audits
Strategies
Create/revise policies and procedures to remedy any of the issues uncovered which require resolution
Conduct training on these polices and procedures for physicians/billing and coding staff
Conduct an internal audit three months after training to determine if a change in behavior (billing practice) has occurred related to the targeted services
Physician Quality of Care Issues on the Horizon Resurgence of review of “Services Not
Reasonable and Necessary” (Items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member are excluded from Medicare coverage) Social Security Act §1862(a)(1)
Physician Quality of Care Issues
Managed Care Issues– Arbitrarily excluding identifiable groups– Regularly denying treatment requests without
physician evaluation– Failing to procure health care specialists for the
network– Making adequate service impossible by
assigning an unreasonable number of patients to an individual provider
Physician Quality of Care Issues
Medicare’s Proposed Criteria for Making Coverage Decisions– Is item/service medically beneficial to a defined
population?– Is there a medically beneficial alternative item
or service currently covered?– Is the item/service substantially more/less
beneficial than Medicare-covered alternative?
Physician Quality of Care Issues
– Will item/service result in equivalent or lower total costs than the Medicare-covered alternative?
Further information:
Quality of Care Information
Coverage Polices
http://www.hcfa.gov/quality/8b2-b.htm
Physician Quality of Care Issues
Private Insurers– Blue Cross Blue Shield of Michigan
Dartmouth Atlas of Health Care in Michigan - studies the regional variations in cardiovascular disease and prescription drug use
Blues claims data is used to analyze use/supply of health care services and regional variation within the state
Variations in hospitalizations, surgery and patient care during last six months of life also being studied www.bcbsm.com/atlas/overview.htm
Physician Quality of Care Issues
CIGNA HealthCare– Elements of Quality
Accreditation by National Committee for Quality Assurance (NCQA)
Preventive Care Guidelines Healthplan Employer Data and Information Set
(HEDIS) Local Quality Management Programs National Quality Management Programs Consumer Health Care Programs
Physician Quality of Care Issues
CIGNA HealthCare – Customer Advisory Boards– Satisfaction Surveys– Consumer-Focused Intervention– Commitment to Customer service
www.cigna.com/healthcare/managers/quality.html
Physician Quality of Care Issues
Aetna U.S. Healthcare– The Quality of Care Research Fund -Academic
Medicine and Managed Care Forum Partnered with academic medical centers and newly
integrated health systems Goal- to bring together institutions that share
interest in raising quality of healthcare and forge collaborative relationship for exchange of ideas and best practices
Developing performance measurements for relaying quality information to providers www.aetna.com/foundation/health/researchfund.htm
Summary
The Quality of Care provided by physicians is directly related to the quality of compliance. Therefore:
Hire the most qualified physicians Monitor the physicians at periodic, set
intervals Audit each physician’s practice pattern
against his/her peers and applicable regulations
Proactively determine payors’ targets
Summary
Audit physician services proactively related to these initiatives
Educate physicians and billing/coding staff regarding the issues uncovered by audits
Monitor all health care regulations and distribute relevant information to physicians and billing staff on a timely basis
Additional Resources
HCFA’s Quality of Care Information
www.hcfa.gov/quality/download/3k1.pdf Local Medical Review Policy (LMRP) for
all Medicare carriers www.lmrp.net State medical practice management and
hospital associations offer various types of additional information on quality