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


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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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


Patient Protection and Affordable Care ActHealth Reform

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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


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


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

g

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


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


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


• 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


• 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


• 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

THANK YOU!

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