Make quality a key part of hospital compliance

Too many are not taking this integrated approach

If you think corporate compliance is somebody else’s responsibility, think again. Although most quality departments haven’t had to shoulder much of the compliance burden, that could — and should — be changing, some experts say.

Judy Homa-Lowry, MS, RN, CPHQ, president of Homa-Lowry Healthcare Consulting in Canton, MI, says that when it comes to corporate compliance, many organizations aren’t taking full advantage of the resources they’ve had in place for years, including quality management.

Using the model compliance guidance for hospitals developed by the Department of Health and Human Services Office of Inspector General as a blueprint, most organizations have consolidated responsibility for compliance under a compliance officer, who in turn reports to the chief financial officer or another high-ranking member of the hospital’s administration. An unfortunate and perhaps unintended consequence of this sort of structure is that the compliance officer controlling the process may not be aware of how other departments could help complement or refine the compliance program. "The thinking tends to be, Well, now we have to do compliance,’ so they start doing things without really tapping into the other systems already in place," Homa-Lowry says.

Homa-Lowry says she became aware of the possible benefits of involving quality management in the compliance effort in her talks with health care attorneys and prosecutors, all of whom stressed the need to monitor and improve compliance processes. "Since [process improvement] is such a routine part of what quality professionals have done for years, it seems like a missed opportunity when they’re not more involved in it."

Significantly, almost all of the risk areas identified by the OIG in its guidance are relevant to quality departments. Examples include the following:

Medical necessity of services. This includes seeking reimbursement for a service that isn’t warranted by the patient’s current and documented medical condition, billing for inadequate or substandard care, and failing to provide covered services or necessary care to members of a health maintenance organization.

Patient freedom of choice. "This area is of particular importance for hospital discharge planners referring patients to home health agencies, durable medical equipment suppliers, or long-term care rehabilitation providers," Homa-Lowry says. Besides resulting in federal penalties, failing to inform patients of their right to choose to be referred to facilities other than those owned by the hospital system might lead to malpractice claims.

Eligibility determinations. This category would include arranging home health services for patients who are not homebound.

Documentation. In a legal sense, if something isn’t documented, it didn’t happen. That’s why it’s crucial to clearly document communications with payers, including preauthorizations, coverage issues, and discharge issues, and to insist that caregivers fully document the services they provide.

Homa-Lowry notes that while accreditation and compliance are different issues, there are parallels, and experience in dealing with standards set by the Oakbrook Terrace, IL-based Joint Com mission on Accreditation of Healthcare Organ i za tions is likely to give quality managers a leg up when it comes to understanding and dealing with compliance issues.

She adds that, in 2000, the Joint Commission is likely to set new utilization standards. "And they’re saying that people are going to need to prioritize and take a look at where resources are being utilized and spent. In order to monitor that, you would use the quality process to look at utilization issues," she says. "If you’re having problems with utilization issues, that could potentially reflect issues in compliance as well."