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