Download - Compliance Quality Webinar
David Way, MAIS, CHC
The Crossroads of Quality and Compliance
Agenda
Defining the Terms
Quality of Care: The OIG weighs in
The driving force for Quality
Healthcare Reform
Compliance as a by product
Initiatives and Incentives
Corporate Compliance: An Overview
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Agenda
The Crossroads
Action Steps to Mitigate Risks
Legal Risks
Discussion
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David Way MAIS, CHC
• ComplianceThe act or process of complying to a desire, demand, proposal, or regimen or to coercion.
-Negativity is a common feeling toward compliance• QualityA ’degree of excellence’, superiority in kind, a distinguishing attribute, an acquired skill.
-Excellence...Superiority, this certainly should conjour up good feelings or pride.
What is in a word?Compliance & Quality
A Paradigm Shift
David Way, MAIS, CHC
tQuality in reducing the expenses and costs associated with non compliance
Quality in reducing poor public perception
Quality in the goods or services produced
Quality
Quality
An ‘effective’ compliance program does not coerce care providers into doing the right thing. The worst circumstance or system requirement is to have to make a demand or coerce human behavior.
The corporate compliance objective is to create quality in the goods of services it produces.
Compliance
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1. Organizations have used the ‘stick’ approach…if you do [this] you will pay. Thinking of compliance as a natural progression forces us to consider individual’s ethical principles. If my standards of conduct are high I likely am committed to the pursuit of excellence [Quality] and therefore will turn to the governing rules/laws and standards to ensure I am doing things legally.
David Way MAIS, CHC
Compliance is a By-ProductCharacter...Excellence...strive for the Best
Integrity
QualityCompliance
David Way MAIS, CHC
• A Perfect Storm IOM’s To ”Err is Human and ”Crossing the Quality
ChasmVoluntary reporting programsDramatic advancements in ITDepeletion of Medicare Trust Fund/Increasing
costs to Medicare programPhysician Compensation Models
Isn’t quality in medicine a no brainer?The Driving Forces for Quality
David Way MAIS, CHC
• Federal and State initiatives to promote high quality, efficient care: Payment Incentives (P4R and P4P)Withholding/decreasing payments for HACTransparency though public reporting
• Health Reform• Physician Compensation Models
Federal Government weighs inHealth Care Quality Initiatives
Incentives
David Way MAIS, CHC
Under the Hospital Quality Incentive Demonstration, a joint effort between CMS and Premier Inc., quality indicators for 260 participating hospitals rose by 11.8 percent over two years. The hospitals are scored on their adherence to 30 nationally standardized measures in five clinical areas: acute myocardial infarction (AMI/heart attack), congestive heart failure, coronary artery bypass graft (CABG), pneumonia, and hip and knee replacement.
Pay for Performance
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Pay for Reporting
tCMS is looking beyond hospitals
Urging state Medicaid programs to consider similar programs
Since 2007 hospitals required to report specified HACs; and
Since 2008 Hospitals are not paid the higher rate for the reportable condition unless it was POA.
Only inpatient…for now.
Payment Disincentives
Started as voluntary initiative in 2003 with 10 quality measures
Now mandatory and involves more measures
Reductions in Medicare payment for failure to report
Data is on the web at hospitalcompare.hhs.gov
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David Way, MAIS, CHC
Demonstration Projects
1Hospital Quality Incentive Demonstration (HQID)
The Physician Group Practice (PGP) Demonstration
3The Medicare Management Performance (MCMP) Demonstration
CMS has released results from three demonstration projects. These projects offered participants incentives to improve patient care with the belief that quality of care would be increased and cost decreased. As the link between payment and outcomes grow stronger, hospitals and physicians should ensure there is oversight to protect the integrity of the data they submit to the government in return for their rewards.
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Quality Affordable HC for all Americans
Boards of Directors are look upon
Prevention of Chronic Disease & Improving Public Health
Revenue Provisions
Improving the quality and efficiency of health care
Transparency and Program Integrity
Strengthening Quality, Affordable health care for All Americans
David Way, MAIS, CHC
Patient Protection and Affordable Care ActHealth Reform
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David Way, MAIS, CHC
The Driving Forces for Compliance
1Integrity
Quality
3Fiscal
With the passage of the Patient Protection and Affordable Care Act of 2010, as amended by the Health Care Education Reconciliation Act of 2010 (the Healthcare Reform Law), Congress for the first time hasmandated that a broad range of providers, suppliers, and physicians adopt a compliance and ethics program. Smaller providers and suppliers may feel the impact of these new compliance program obligations most acutely given that many, if not most, larger healthcare providers already have some form of compliance program.
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Seven ‘Voluntary’ StepsCompliance Program
David Way MAIS, CHC
Designate a Compliance Officer
Responding to Detected Offenses and create Action Plan
Conduct Effective Training and Education
Enforcing Standards through well publicized Guidelines
Written Policies and Procedures
Develop effective lines of communication
Auditing and Monitoring ✓
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David Way MAIS, CHC
Increasing OversightOIG Focus on Quality of Care
Quality of Care is a top enforcement priority. Prosecutors have used civil and criminal statures to punish substandard car, and Medicare watchdogs have increasingly deployed auditors to examine quality related issues.
• Quality of Care CIAs – Key Focus Area 28 Quality of Care CIAs as of 1/4/2011 Additional Internal Requirements Quality of Care Review Program Board of Directors Dashboard – Communication Competency based training requirements
David Way MAIS, CHC
Increasing OversightOIG Focus on Quality of Care
The HHS Office of Inspector General’s annual work plan targets quality, and in 2011 had an item on “Hospitals’ controls for ensuring the accuracy of data released to quality of care, which they submit to CMS for Medicare reimbursement.
• Government and private payers shift attention Medical necessity and quality of care is focal point The lines between coverage determinations and the
government’s expectation of clinical practice seem blurred.
Current investigations appear to be focused on physicians medical judgment rather than types of documentation and coding cases we have seen in the past.
David Way MAIS, CHC
Increasing OversightOIG Focus on Quality of Care
Quality must be a core measure of all we do.
• Government and private payers shift attention Increasing trend to hold hospitals accountable for
the physicians’ decisions within the four walls of the hospital.
Due to the changing invironment, it is becoming critical for compliance officers to work with clinical and quality departments to evaluate processes and limit exposure from not only an outcomes perspective but also a compliance perspective.
David Way MAIS, CHC
Quality of Care Corporate Integrity Agreements
Quality must be a core measure of all we do.
• CIA When a False Claims Act settlement resolves allegations of fraud that impact the quality of patient care, OIG may enter into a "quality-of-care" Corporate Integrity Agreement (CIA) with the settling provider. Under this type of CIA, OIG requires that the provider retain an independent quality monitor. The quality monitor not only will address the specific issues underlying the allegations, but also will look at the entity's delivery of care and evaluate the provider's ability to prevent, detect, and respond to patient care problems.
David Way MAIS, CHC
Reimbursement is moving toward a “quality based” system. Non compliance with measures may not be reimbursed or may generate an external audit
Quality Management is typically an operations function. QM practices are driven by standards. Sometimes QM departments may function as a silo.
Compliance is typically a staff person responsibility. These individuals conduct trainings, they monitor and audit internal systems for compliance. They must collaborate for success through systems, shared reports and committee membership.
Important Considerations
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Compliance
QM.
reimbursement
1. Compliance is the act of conforming with stated requirements. Organizationally, it is achieved through management processes which identify the applicable requirements, assess the state of compliance, assess the risk and potential costs of non compliance against the projected expenses to achieve compliance, and hence prioritize, fund and initiate any corrective actions deemed necessary.
David Way MAIS, CHC
The CrossroadAn inetgral convergence
Quality Management
Auditing
Monitorin
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Credentialing/Screening
Profession
al Standards
Compliance
David Way MAIS, CHC
• Involve all units and all risk management departments (legal, compliance, HR, Quality etc.)
• Discuss priorities, overlap and coordination
• Create annual work plans • Integrate committees, if possible.
Managing the Intersection
David Way MAIS, CHC
• Management...Lack thereofHospitals have been penalized for conduct such as chronic understaffing, reckless imposition of budgetary constraints that impaired patient care, and reckless submission of claims.
Learning from others.Legal Risks
David Way MAIS, CHC
• False Claim Act LiabilityThree primary theories of liability, predominantly triggered under the FCA by claims reimbursement
• Provision of medically unnecessary services• Provision of care so deficient that it amounts to no
care at all, such that the claims are essentially for services not rendered.
• Implied or false certification
Learning from others.Legal Risks
David Way MAIS, CHC
• Potential Provider Fraud Related to Federal Health Care Quality Initiatives
• Billing for services not provided• Upcoding – billing for a higher level of service than
was provided, or billing for services that did not meet the P4P or P4R incentive payment conditions
• Failure to provide appropriate care• Unnecssary and incorrectly performed procedures• Poor Quality – intentional low quality care to save
money
Learning from others.Legal Risks
David Way MAIS, CHC
Action Steps to Mitigate Quality of Care Risks
• Improve Quality Compliance Oversight– Quality must be on same par with financial and
regulatory– Must identify relevant quality/safety issues and
establish a system for performance goals and monitoring elements to ensure compliance.
– Solicit subject matter experts in compliance activities
David Way MAIS, CHC
Action Steps to Mitigate Quality of Care Risks
• Engage Leadership– Must promote the reporting of quality concerns and medical
errors and protect those reporting– Ensure sufficient resources to support patient quality and safety– Must measure resource changes in the context of quality and
safety outcomes/measures– Competency assessment and training, credentialing, and peer
review must recognize necessary clinical and safety issues– Must identify and report ‘adverse patient events’ so they are
analyzed and incorporated into the QI activities
David Way MAIS, CHC
Action Steps to Mitigate Quality of Care Risks
• Employ Education Strategies– Standardize and evaluate education efforts– Keep records of quality-of-care education and attendance– Provide profession/risk specific training
• Executives• Board Members• Physicians• Direct care
David Way MAIS, CHC
Action Steps to Mitigate Quality of Care Risks
• Accountability– Transparency and accountability are here to stay– Make accountability part of the fabric of your organization– Move from avoiding risk to maximizing excellence– Be patient…it takes time
David Way MAIS, CHC
In our DNAQuality and Compliance
The pursuit of quality and the commitment to comply must be imbedded in the DNA of the organization. Employees must ‘want’ to do the right thing and feel safe and empowered to report deviations from best practices, policies, procedures etc.
The Continuum
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Quality Compliance
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