Kusserow on Compliance: False Claims Act settlements on the risk spectrum

OIG reported results of action taken in FY2019

The government’s primary civil tool for addressing health care fraud is the False Claims Act (FCA) and most of these cases are resolved through settlement agreements in which the government alleges fraudulent conduct and the settling parties do not admit liability. Based on the information it gathers in an FCA case, the OIG assesses the future trustworthiness of the settling parties (which can be individuals or entities) for purposes of deciding whether to exclude them from the federal health care programs or take other action. The OIG applies published criteria to assess future risk and places each party to an FCA settlement into one of five categories on a risk spectrum. OIG bases its assessment on the information OIG has reviewed in the context of the resolved FCA case and does not reflect a comprehensive review of the party.

The OIG published its FCA risk spectrum report for 2019. The amount of settlements was not part of this report but will be provided separately later. There were fifteen entities excluded based on FCA violations. Another 40 entities entered into Corporate Integrity Agreements (CIAs), which was at about the same rate as in recent past years. Also reported were two cases where the entity was placed on Heightened Security, rather than signing a CIA. In addition there were twelve self-disclosures related to FCA violations reported.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2019 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Medicare overpaying for graduate medical education (GME)

A study published in the Journal of the American Medical Association (JAMA) Internal Medicine raises questions about overpayments by Medicare for graduate medical education (GME) to train residents. By way of background, the Medicare Program makes payments to teaching hospitals for training physician residents. These payments are known as GME payments. Hospitals may also incur real and significant costs beyond training residents in the patient care setting. For those such costs, the Medicare Program makes direct GME (DGME) payments to hospitals for added direct costs incurred by teaching hospitals, such as stipends and/or fringe benefits paid to residents or to faculty who supervise the residents. The JAMA reported study suggests that if Medicare capped funds for GME at $150,000 per resident, it would free up over $1 billion a year and use the savings to address the shortage of doctors in certain specialties in underserved areas. The training of residents is funded by GME payments made to hospitals and health systems, largely through Medicare and Medicaid. Researchers examined cost reports to calculate GME payments to hospitals from 2000 to 2015 at among 1,624 teaching hospitals. The study found GME payment rates to hospitals in 2015 varied significantly, with 25 percent of hospitals receiving less than $105,761 while 25 percent received more than $182,233 per resident. Nearly half of teaching hospitals received more than the $150,000 per resident rate.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on LinkedIn.

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Copyright © 2019 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Five major ambulatory risk areas

The Emergency Care Research Institute (ECRI) Institute analyzed 4,355 adverse events reported and found diagnostic testing errors pose the biggest risk to patients in ambulatory care settings with nearly half occurring in physician practices. Nearly half involved diagnostic testing errors with one fourth relating to medication safety and the remaining involving falls, security, and safety and privacy-related risks. The following risk areas were cited: 

Diagnostic testing errors. This is the leading cause of liability claims against primary care doctors and accounts for the highest proportion of payouts. Most of these errors involved laboratory tests. Other tests where problems occurred included imaging tests, pathology, and cardiology.

Medication safety events. Two-thirds of safety events were classified as wrong drug, wrong patient, or wrong time, the analysis found. Medication errors are a leading cause of malpractice claims in ambulatory care and can occur during any stage of the medication process. They are often the result of a series of failures within a system, the report said.

Falls. About half of the 800,000 hospitalizations from fall-related injuries occur in ambulatory settings in the exam room or waiting room.

HIPAA violations. Misunderstandings concerning HIPAA privacy and security rules prompted more than 350 HIPAA-related events to be reported to the ECRI Institute. The majority of these pertained to inadvertent disclosure of patients’ protected health information.

Security and safety incidents. Most such events involved verbal threats or disruptive behavior by patients or visitors.

Tips to Reduce Risks

 

  1. Provide decision support tools to assist in ordering the proper tests and monitoring processes for test tracking and follow-up.
  2. Standardized medication management procedures and create a policy directing how to report and manage safety events.
  3. Screen patients for fall risk at every visit, when a change in condition occurs and after a fall.
  4. Train staff on HIPAA Privacy/Security rules, particularly as they relate to disclosure of PHI.
  5. Train staff on what to do in the event of a violent incident and conduct monthly security and safety surveillance rounds.

 

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2019 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: New CMS proposed outpatient rules

The 2020 annual rule cycle has been active for CMS with several proposed rules in the outpatient prospective payment system (OPPS) area. Hospitals and health system executives should monitor these annual rules carefully for provisions that will affect their organizations’ operations. Among the significant regulatory rule proposals for hospital and health system executives are the following:

  1. Mandated disclosure of negotiated charges between health plans and hospitals for all items and services for about 300 “shoppable” services
  2. Proposed penalties which would be over $100,000 a year for noncompliant hospitals
  3. The addition of several ASC procedures
  4. The removal of total hip arthroplasty from the inpatient-only list for 2020, allowing the procedure to be performed on an outpatient basis
  5. Reduction of supervision level for hospital outpatient department from direct to general for hospital outpatient departments
  6. A requirement for prior authorization of certain outpatient department services.
  7. Continued payment reduction for 340B purchased drugs
  8. Increased per-day cost threshold for separate payment for certain outpatient drugs
  9. The establishment a prior authorization process for five categories of services that often may be cosmetic: blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation
  10. Various updates to Hospital Outpatient Quality Reporting Program requirements

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2019 Strategic Management Services, LLC. Published with permission.