Unannounced survey may follow quality infractions
Unannounced survey may follow quality infractions
Joint Commission clarifies its stance
An allegation of fraud by a federal agency is not enough to spur a for-cause, unannounced survey by the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, says Janet McIntyre, Joint Commission spokeswoman.
"The key is quality of care, not just financial fraud allegations," she says. The organization’s policy reads as follows: "If there are allegations of financial fraud that suggest that the quality of care might be affected, the Joint Commission will take quick action to investigate. Depending on the seriousness of the issue, the Joint Commission can perform a for-cause, unannounced survey."
Subacute Care Management asked McIntyre under what circumstances fraud allegations would affect quality of care.
"Fraud and abuse allegations must lead to concerns about quality of care," she responded. The following scenarios describe actions taken for financial reasons, but which ultimately affect patient care:
• Providing and billing for medical services not needed.
This means an organization is not only billing for unnecessary services, but it has actually provided for the patient something he did not need.
• Discharging a patient on a date that reflects the expiration of insurance of length of stay for DRG, despite the fact the patient needed additional treatment.
• Keeping a patient until insurance payments are exhausted (if on a daily rate rather than a capitated rate), even though the patient no longer needs to be there.
McIntyre cites upcoding as an example of a financial fraud allegation that might not call quality of care into question. In that case, there’s no suggestion the organization hasn’t provided proper care for its patients. (For more on fraud and abuse, see p. 21.)
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