QUALITY RELATED TO PHYSICIAN SERVICES Judy A. Coy

1. QUALITY RELATED TO PHYSICIAN SERVICES Judy A. Coy

2. 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

3. 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

4. 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

5. 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?

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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”

13. 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

14. 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

15. 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

16. 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)

17. 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

18. 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?

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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