Keys to Educating Physicians on Fraud/Abuse and Obtaining Compliance Buy-In

How does your organization rate when it comes to ensuring that physicians with privileges and staff physicians understand how noncompliance affects them and why it is important for them to buy-in to your organization’s compliance program?

A major concern for compliance officers continues to be ensuring that physicians understand their role in preventing fraud, abuse, and waste and getting them on board with the organization’s compliance program. Health care professionals discussed this issue at the Health Care Compliance Association (HCCA) Compliance Institute held in Las Vegas, April 29 through May 2. A break out session titled “Educating Physicians: Preventing Health Care Fraud, Abuse, Waste & Malpractice,” presented by Scott Jones, CHC and Richard E. Moses, DO, JD, addressed the confluence of quality of care, medical malpractice, and compliance and provided practical advice for educating physicians.

Moses and Jones began their presentation by establishing the connection between quality of care, medical malpractice, and compliance. Moses explained that compliance is risk management and that today’s risk model involves risk management, including medical malpractice; regulatory compliance; and quality management. Among the major demands on a health care system identified by Moses and Jones are the public perception of quality concerns, the physician and nursing shortage, increased government oversight, increased volume of patients, decreasing reimbursement, and qui tam and medical malpractice lawsuits. In addition, the goals of health care reform as it is today, include  increased quality reporting to include outcomes, increased integration of care through partnerships with physician networks and hospitals, and cost control and cost reduction.

Areas of Risk Exposure

Jones discussed four areas where a physician’s exposure to risk is significant. He began by identifying overlapping circles of risk, those being quality improvement, regulatory compliance, medical performance, medication management, medical records, patient safety, and employee safety.

  • The first area of risk specifically includes record documentation, informed consent deficiencies, inadequate patient education, poor physician-patient communication, poor-physician-physician-nurse- communication, lack of medical necessity for performed medical services, improper performance of medical services. Quality failures that could be improved through education and complete documentation, according to Jones, are inadequate informed consent, missed abnormal test results, incomplete history and physical, medication management errors, and patient handoff.
  • The second area of risk Jones discussed was quality of care investigations. As Jones described it, overutilization or unusual utilization triggers investigation. Investigation leads to publicity and possibly medical malpractice suits. Hospital/physician arrangements are at risk, hospital survival is at risk and physician licensure is at risk, Jones said.
  • Medicare contractor audits pose the third area of risk for health care providers. Recovery audit contractors’ (RACs) reports indicate that 40 percent of the overpayments identified were due to lack of medical necessity. Using data mining and analysis Zone Program Integrity Contractors (ZPICs) predict patterns to detect , deter, and prevent Medicare fraud, abuse and waste. A ZPIC audit is triggered when there is high utilization of services or items, high cost services or items, or inadequate documentation.
  • The fourth area of risk exposure is HIPAA privacy and security rules. Physician need to be educated regarding the fines and penalties for data breaches and loss of protected health information (PHI) and need to have controls in place to prevent breaches, Jones said.

Developing a Training Program for Physicians

To build a training program for physicians, compliance officers must understand how physicians think and how they communicate, according to Moses, who during the presentation used his experiences and reactions as a physician to illustrate how a physician might respond to approaches by compliance officers. To get physician’s interested in compliance, Moses recommended that compliance officers focus on the role of compliance in preventing medical malpractice and avoiding reports to the National Provider Data Bank (NPDB).  The NPDB receives and maintains records of malpractice judgments and disciplinary actions against licensed health care professionals. It provides hospitals and other health care entities with information related to the professional competence and conduct of physicians and other health care practitioners.

Physician perspectives

Physicians’ main goal is to deliver quality care in an effective safe manner; they receive little if any training about fraud and abuse and malpractice, and they do not understand compliance, Moses pointed out. He then provided the following additional insight:

  • Physicians are taught to assess, diagnose, implement correct treatment action, and be responsible for outcomes;
  • Physicians are competitive and tend to be detailed overachievers and/or survivors;
  • Physicians have little tolerance for ambiguities;
  • As scientists, physicians respect facts and data that can be supported by research;
  • Physicians understand but often dislike peer review;
  • Physicians dislike being embarrassed before peers;
  • Physicians generally want to do the right thing but for compliance may not know or understand what the right thing is.

Teaching principles

The teaching principles identified by Moses included maintaining a positive attitude, complimenting and encouraging physicians and avoiding confrontation and intimidation. The approach should be helpful and supportive and physicians should be encouraged to share their experiences, Moses said. Approach education with a teamwork philosophy, tell physicians how they can help, and request feedback. When feedback is received, review it and act on it. He also suggested that a positive way to let a physicians know how they are doing is to rate them against their colleagues.

When approaching physician education, Moses noted that one size does not fit all programs and one teaching method is not enough. For example, what will work for employed physician may not work for private physicians. In addition, each organization has unique needs. The program needs to be flexible because areas of malpractice and compliance risks evolve and change with time. When developing a program the compliance officer should consider (1) the size and type of the practice to be educated; (2) the physical location of the practice; (3) the methods and venue of physician education; (4) that education should be continuous, it is not a one shot deal; (5) the topics to be covered; (6) the time allowed for the training; and (7) the budget. The compliance officer also should consider whether the physicians are residents, fellows, or foreign physicians.

In terms of the topics covered, they should be relevant and necessary and should include education required by law, the top ten repeated areas found in the Office of Inspector General workplan, and areas of risk that have surfaced within the health care organization and externally at other health care organizations. The topic should be explained and background information and a reference identifying where it came from should be provided. In terms of time allowed, physicians may be more interested in attending training if there are continuing medical education credits offered as required for licensure, ethics, risk management, and patient safety.

What methods for training physicians on compliance  have been successful in your organization?

Richard E. Moses, DO, JD is board certified in gastroenterology, internal medicine, and forensic medicine. He is an adjunct assistant clinical professor at Temple University School of Medicine, an adjunct professor of law at Temple University, Beasley School of Lawand a physician advisor at Healthcare Providers Insurance Exchange (HPIX).

D. Scott Jones, CHC, is the Senior Vice President Claims, Risk Management & Corporate Compliance at HPIX. He currently leads a team managing over 600 quality claims daily and has conducted over 1000 risk assessment service visits to health care organizations. He is a board certified healthcare compliance officer and a licensed healthcare risk manager.