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.

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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: Choosing a location for investigation interviews

Regardless of whether you are conducting a debriefing of a complainant, interviewing a witness, or confronting a subject in an interrogation, determining the location and setting of the interview is important. The objective is to create privacy and eliminate any possible interruptions or distractions. It should be conducted away from any traffic or other distracting influences, or where others may observe or overhear what is occurring. Interviewing someone in their own office should be avoided in that it invites interruptions or reasons why the person may turn their attention to some other matter. It also gives the interviewee the advantage of being on their “own turf.” By interviewing someone away from their own area, the investigator receives an advantage. The following are some additional tips and considerations in deciding upon the interview location and setting:

1. Privacy. Fewer the people in the room, the better the results
2. Quiet. Don’t want external sounds or outsiders to hear
3. Room Size. Small enough to convey intimacy
4. Well Lighted. Permits closer observation of individual
5. Plain. Avoid distractions (e.g. window, pictures, wall clocks, etc.)
6. Telephone. Shut if off to avoid incoming calls/messages
7. Furniture. Avoid having furniture in between (barrier to rapport)
8. Seating. Interviewer should sit directly across from interviewee
9. Positioning. Avoid the person being able to look out a window and not at you

It is recognized that there are practical constraints that may necessitate compromise on these considerations. Also, most interviews will be persons who are witnesses or who otherwise provide limited information. As such, many of these tips may not be necessary. However, if the person to be interviewed is the subject of the investigation, applying these principles become important elements to successful outcomes.

 

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: CMS issues final rule on affiliation disclosure requirements for the provider enrollment process

CMS issued a final rule on September 10 that sets forth requirements mandating providers and suppliers who submit an application for enrollment or revalidation for Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP) disclose current or previous (up to five years) affiliations with a provider or supplier who has uncollected debt; has been or is subject to a payment suspension under a federal health care program; has been excluded from participation from Medicare, Medicaid, or CHIP; or has had billing privileges denied or revoked. CMS said a history of bad actors trying to escape the ramifications of inappropriate or fraudulent behavior by re-entering the program in some capacity, and/or shifting their activities to another enrolled Medicare provider or supplier with which they are affiliated, provided the motivation for the rule. In addition to furnishing the disclosure information, the provider must submit: (a) an organizational diagram identifying all of the entities listed in this section and their relationships with the provider and with each other; and (b) if the provider is a skilled nursing facility, a diagram identifying the organizational structures of all of its owners.

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.