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: 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.

Kusserow on Compliance: OIG Work Plan update on Hospital Sector

The HHS Office of Inspector General (OIG) Work Plan sets forth various audits and evaluations that are underway or planned during the fiscal year and beyond. Since June 2017, the OIG modifies the plan monthly to add new items and remove completed ones. When developing its plans, the OIG assesses relative risks in HHS programs and operations to identify those areas most in need of attention. The OIG recently reported updates to its planned work in the hospital sector that include:

  1. Determining whether: (1) skilled nursing facility (SNF) level of care was certified by a physician or a physician extender; (2) a condition treated at the SNF was one which the beneficiary received inpatient hospital services or a condition that arose while receiving care in a SNF; (3) daily skilled care was required; (4) services delivered were reasonable and necessary for the treatment of a beneficiary’s illness or injury; (5) improper Medicare payments were made on claims reviewed; and (6) hospital admissions were potentially avoidable.

 

  1. Reports on a data brief that describes nursing staffing levels reported by facilities to the Payroll‐Based Journal; examination of CMS’s efforts to ensure data accuracy and improve resident quality of care.

 

  1. Determining whether CMS corrected the common working file (CWF) edits and ensured they are working Prior review found that CMS CWF edits related to transfers to home health care, SNFs, and non‐IPPS hospitals were not working properly.

 

  1. Review of overstated Medicare charges on outpatient claims that contain both an outlier payment and a reported medical device credit to determine whether Medicare payments for replaced medical devices and their respective outlier payments were made in accordance with Medicare requirements.

 

  1. Determine how inpatient hospital billing has changed over time and describe how inpatient billing varied among hospitals and will use results to target certain hospitals or codes for a medical review to determine the extent to which the hospitals billed incorrect codes.

 

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.