Investigators set to target poor quality of care
Investigators set to target poor quality of care
Court deals further blow to FCA enforcement
State and federal health care investigators find allies in private payers and peer review organizations
The Department of Health and Human Services’ (HHS) Office of Inspector General (OIG) last week released its 46-page Workplan for FY 2001. But while providers would be well-served to scan the federal government’s latest blueprint for combating health care fraud, it would be a mistake to limit compliance efforts to the areas included in the report.
OIG spokeswoman Judy Holtz warns providers not to read the document too literally. "The Workplan is only a road map of the things that are on our plate for the coming year," she explains. "It can change weekly or monthly, and many parts of it have not even been assigned."
Even so, one likely focus of state and federal prosecutors will be poor quality care, according to experts at the Philadelphia-based Health Care Compliance Association’s (HCCA) recent meeting in New Orleans. "It is a big issue and it is going to get bigger," warns Jim Sheehan, Assistant U.S. Attorney in Philadelphia. As many hospitals reduce their staffing in areas such as nursing, Sheehan predicts the crackdown on poor quality already under way will intensify significantly.
In fact, Sheehan says, providers should brace for a convergence of compliance activity and the issue of quality in the coming years. He says investigations will encompass every area of the health care continuum, from managed care to nursing homes. "If you are looking to see where compliance is going to go, the issue of quality is on the radar screen for our office, the U.S. attorney system, the U.S. Department of Justice, and the OIG."
Sara Grim, CEO of the Missouri Peer Review Organization (PRO), says compliance officers would be well served to take note of the new role of PROs. "We are sort of the light side of the regulatory environment," she says. "But now that we have endeavored to go into the payment error prevention program, we also have a dark side."
Grim says compliance officers must begin looking for patient care compliance issues in unusual places. She cites a recent survey that found hospitals often fail to review same-day readmissions for premature discharge or billing errors. "[Hospitals] assumed that a same-day readmission review looked solely at utilization," she explains. "They did not look at premature discharge, and they did not look at billing."
Worse yet, fiscal intermediaries lacked the edits to catch same-day readmissions, much less something as simple as two hospitals billing the same-day readmission using a shared provider number. "That had been going on for 15 years, but nobody caught it," she asserts.
Grim contends that most quality-of-care issues aren’t terribly complex, however. In fact, the most commonly identified problems relate to defects of process and defects of knowledge, such as poor quality assurance controls over established policies and procedures and inappropriate or inadequate written policies and procedures. She also cites poor communications processes between physicians and hospitals or health plans and an overall lack of accountability and responsibility within the health care system.
Vicki McCormick, corporate compliance officer for United Health Group in Minnesota, cautions providers that while payers do not typically make findings of fraud, they are increasingly targeting improper billing as well as quality of care.
McCormick points out that 38 states now have insurance fraud bureaus, 14 states require health care payers to have an anti-fraud plan, and eight states require special investigative units (SIU). There is overlap between the latter two groups, and some states also require an SIU if there is no anti-fraud plan, she adds.
On top of that, another 11 states now require annual reports on anti-fraud activity, and that number is growing, McCormick reports. "Even more importantly, 33 states require an insurer to report suspected fraud," she says. Meanwhile, another seven states now demand training to increase awareness, and that number is growing as well, says McCormick.
The potential trouble spots for providers are not limited to quality of care, however. High on Sheehan’s list of growing compliance issues are the relationships of drug and device manufacturers with hospitals and other organizations. This is no longer a threat facing only research institutions such as the recent cases against Beth Israel in Boston and Thomas Jefferson in Philadelphia, he says.
Instead, Sheehan reports that across the country these relationships are receiving close scrutiny. If Congress passes a Medicare prescription drug benefit, the use of drugs in hospitals and physicians’ offices is almost certain to become a "much hotter issue," he says. That includes financial relationships within these organizations and how they handle patients as well as how they approach quality issues in the research context, he adds.
Sheehan says that coding and billing systems, not only of providers but also insurers, represent another area that should not be overlooked. He says one of the most difficult issues right now is what he calls "electronic due process." Historically, claims submitted to insurance companies were systematically evaluated. But today many of those systems do not work well in part because they reject valid claims, he argues.
In fact, Sheehan argues that not paying for services rendered is just as fraudulent as billing for services not rendered. "I predict that in the next couple years we are going to see a significant growth in those kinds of cases," he asserts. The good news for hospitals is that will include not only how claims are adjudicated for payers but for providers.
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