QUALITY RELATED TO PHYSICIAN SERVICES Judy A. Coy

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QUALITY RELATED TO PHYSICIAN SERVICES
Judy A. Coy
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Unnecessary Services Land Surgeon in Jail

• Massachusetts orthopedic surgeons 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

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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

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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

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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?

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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

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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

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Re-credential Current Providers

• Remember the OB/GYN doctor who carved his
  initials into his patients abdomen?
• Physician permanently surrendered license, was
  indicted on assault charges
• Hospital neglected to report incident to state
  authorities

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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

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Results of Not Reporting Incident

• Selected consultant also had to complete a
  hospital-wide study of the facilitys quality
  assurance and credentialing programs
• Lessons to be learned
• Re-credential medical staff at set intervals
• Tie compliance to credentialing process

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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

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Strategies to Put Quality in Your Compliance
Program

• Follow your institutions credentialing and
  re-credentialing procedures/policies
• Perform data analysis of each physicians
  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

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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

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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

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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

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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)

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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

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Physician Quality of Care Issues

• Medicares 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?

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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

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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

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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

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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

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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

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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 physicians practice pattern against
  his/her peers and applicable regulations
• Proactively determine payors targets

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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

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Additional Resources

• HCFAs 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