The government has been increasing its focus on healthcare fraud involving “quality” of care.  This is an extremely difficult issue, especially for prosecutors.  It is very difficult to define “quality” standards and then base civil and criminal prosecutions on violations of these standards.  Healthcare providers can always walk into court and claim they were trying to provide their patients with the “best” care possible.

When you peel back the layers on these issues, there can be glaring examples of abuse.  For that reason, the Justice Department and HHS have every reason to focus on this issue.  Healthcare providers need to act proactively to document their quality standards and adhere to these policies to defeat any claim of abuse or criminal intent.

Quality care cases have occurred in three major areas: (1) short-stay admissions; (2) percutaneous coronary intervention (stents); and (3) automatic implantable cardio-defibrilators.

Physicians have a range of discretion in prescribing these treatments in order to ensure Medicare coverage.  Hospitals are under scrutiny for doctors’ who prescribe “medically unnecessary” services under Medicare.  In the last few years, doctors and hospitals have been prosecuted aggressively for overuse of stents in patients where their medical condition did not warrant the use of such a procedure.

A Maryland doctor was recently sentenced to eight years in prison for falsifying records and over-prescribing use of stents.  A hospital was fine $22 million for a doctor’s over prescription of cardiac stents.

The challenge for compliance officers is how to focus on quality of care issues to avoid potential exposure for a hospital.  The lines here are not very clear since compliance is at risk of intruding into physician discretion.  It is even more difficult when compliance officers have to exercise oversight of doctors who are not employees at the hospital.

A compliance officer needs to ensure the following steps are taken:

1.  Auditing medical records to make sure that orders for services are clear and the justification is explained in the records.  Compliance officers have to try and ensure consistency in standards among physicians and in record-keeping practices.  In some cases, compliance officers should try to intervene and have an independent review committee affirm any decisions in close cases.

2.  Developing a good working relationship with the medical staff to ensure buy-in to your oversight program.  Medical professionals fear prosecution and, in many cases, favor increased oversight.  Adding peers to the review process can sometimes be viewed as a positive step.

3.  Defining standards for over-utilization and quality care is a very difficult process.  Compliance officers are sometimes seen as establishing minimum standards of care – a threshold figure which would justify a particular procedure.  That is a big mistake.  Instead, compliance officers need to work with quality groups to define better criteria for measuring quality of care.

4.  Communication with providers and staff is key to developing effective compliance protocols.  Compliance officers have to spend time explaining a quality oversight program and why it is necessary.  Training programs help to get the message out.  Hospitals are doctors are constantly under scrutiny on the issue of over-utilization and proactive compliance programs help to prevent any potential problems.