Fraud, Waste and Abuse (FWA)

Karen Shifflett worked as a Federal investigator (Special Agent) for 24 years with the Department of Justice (DOJ) and Department of Defense (DOD); she retired 10 years ago.  She is now working as a Provider Fraud Analyst with the Provider Fraud Team for the U.S. Postal Service, Office of Inspector General (USPS OIG) on criminal and civil cases that are prosecuted by the U.S. Attorney’s Office and DOJ. The cases involve fraud in the Federal worker’s compensation program.   She works on joint cases with the FBI, Health and Human Services (HHS) OIG, Department of Labor (DOL) and other investigative agencies, including the Medicaid Fraud Control Unit (MFCU) for the Texas Attorney General’s Office.

Karen answered questions on Fraud, Waste and Abuse (FWA) that were submitted by nurses with KDJ Consultants.  Three of these questions are presented in this blog post.

KDJ 1.  What should we be looking for when doing routine medical record review? 

Karen:   When I look at a medical record, I look at all the billing records and compare to the provider’s documentation.  This is much more comprehensive than looking at only provider documentation.  A red flag is therapy notes that are duplicative in nature with few or no changes over time except the date of service.  I understand electronic health records (EHRs) use standardized templates, but a legitimate progress/therapy/treatment note is going to have small changes, even if only a change in pain level.  We look for patterns. We follow up with interviews, usually of former employees and patients.  We often find that the patient is no longer going to the provider, but the provider continues to charge for visits, procedures and prescriptions.  This can go on for years. You may also see a lack of medical justification and documentation for ordering procedures or medications for something unrelated to the primary or secondary diagnosis.

KDJ 2.  When we notify a client of a potential FWA violation, what happens next? 

Karen: If a FWA suspicion is reported to a client, they generally refer it to their internal reviewers.  If they find there is a potential FWA violation, it is reported to federal officials, depending on the nature of the violation.  Federal agencies that review FWA include HHS, the DOL, Office of Workers Compensation, Office of Personnel Management, and OIG.  The federal departments often work together because providers may be billing multiple programs. The National Healthcare Anti-Fraud Association (NCHAA) is a great resource and offers training that is available to both government and private organizations.   If enough evidence is found to support the complaint or allegation, it could be referred to the U.S. Attorney’s Office. This generally involves losses that are high-dollar. Some health plans will send providers a letter of education to put them on notice.  The letter may state a specific monetary amount that the plan believes was an overpayment, and the plan may recoup the money through future disbursements to that provider.  Most matters are never referred for criminal investigation, often due to the amount of the loss or the level of available resources.

KDJ 3.  What best practice advice could you give providers to prevent FWA beyond regular CMS training?

Karen: Red flags that providers need to be aware of are lack of medical justification, unbundling codes, services not rendered, duplicate billing, and late claims.  They should have annual training for their staff and themselves.

Some of the most interesting cases have involved Compound Pharmacies and Physical Therapy (PT) clinics.  Most pharmacy cases involve “compound medications” that are not actually compounded but are relabeled off-the-shelf medications.   Some cases involve kickbacks to providers to order these “compounded” drugs, and the physicians are indicted also.  Cases involving PT clinics may reveal no licensed medical providers are working at an alleged PT clinic, yet the clinic is billing for professional services rendered several times per week.  These cases often involve fraudulent billing of millions of dollars. The federal agencies do need to put more safeguards and edits in place to help identify billing anomalies earlier.

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Overview

Transitioning from a medical setting to a new environment after hospitalization is a very vulnerable time for patients, and one that must be monitored closely to ensure successful overall treatment. The National Committee for Quality Assurance (NCQA) has developed the Transitions of Care (TRC) measure as part of their HEDIS^® measure set to better track the timely continuity of care following an inpatient discharge.

Moda Health,  a health insurance company based in Portland, Oregon, reached out to KDJ consultants for assistance improving rates and star ratings for the Transitions of Care (TRC) measure.  As healthcare catalysts on a mission to improve healthcare outcomes through reliable, accurate, and secure medical record review, the expert team at KDJ Consultants worked together to build a plan that would help Moda Health reach their goals.

Solution

KDJ Consultants worked with the client to develop a data entry tool and export system to capture required data elements for appropriate supplemental data HEDIS^® reporting. From there, KDJ Consultants received a monthly file from the client to identify members that met inclusion criteria for the Transitions of Care measure based on their discharge from an inpatient facility in the prior month. Through remote EMR access or fax/mail, KDJ Consultants was able to request medical records, abstract those records using the NCQA (National Committee for Quality Assurance) HEDIS^® TRC technical specifications, and input them into the data entry tool. Monthly reports were provided to the client, and support was provided to complete the required primary source verification audit.

Results

As a direct result of this work, the client saw improved rates for the TRC measure and was able to reduce the medical record review burden during medical record review season by utilizing the supplemental data reporting. Both the client and KDJ Consultants were able to review records in an extended time frame, which allowed for additional follow up, internal discussion, and questions to the auditor and NCQA based on findings.

“Moda Health recommends KDJ Consultants for anyone looking for a partner to support their HEDIS^® TRC objectives. Through their expertise and dedication, we witnessed a significant increase across all four TRC sub-measures, demonstrating a clear improvement in our data quality. Notably, KDJ’s contributions directly enhanced our ability to locate and retrieve the correct member charts, streamlining our processes. We highly recommend KDJ Consultants to any organization seeking impactful and measurable improvements in their HEDIS^® performance.”

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KDJ Consultants had the privilege of assisting HealthTexas Provider Network (HealthTexas) in their commitment to improve the quality of care delivered to patients. Through a strategy of Clinical Transformation, HealthTexas began by measuring how well they deliver preventive services. Then they trained groups of physicians, nurses and administrators to be quality champions, and moved to the development of the Patient-Centered Medical home model. HealthTexas made remarkable progress in developing and implementing effective quality improvement initiatives.

HealthTexas is a multi-specialty, physician-led, patient-centered medical group practice established in 1994 with more than 500 primary and specialty care physicians across Texas. It is a subsidiary of Baylor Scott and White Health Care System. HealthTexas’ passion is the continuous improvement of quality of care for the people they serve. Their mission is to achieve excellence in the delivery of accessible, cost-effective, quality health care, resulting in demonstrated customer satisfaction regarding the value delivered to patients, payers, and the community.

HealthTexas’ Adult Preventive Healthcare Services (APHS) initiative was based on a Patient Safety report published by the Institute of Medicine which points out that patients lose their lives in the ambulatory care setting by errors of omission as well as by errors of commission. That is, lives are lost not only because of what is done to patients, but also because of what is not done for patients. Based on this evidence, HealthTexas put APHS processes in place that enabled physicians to monitor patient follow-through in obtaining a recommended service that could result in early detection of chronic or potentially fatal diseases.

In the early stages of HealthTexas’ APHS initiative, the Best Care Committee designed a study to audit the medical records of all primary care physicians for the following evidence-based adult preventative measures (USPSTF):

• tobacco use and counseling,
• cholesterol,
• colorectal cancer screening,
• breast cancer screening,
• cervical cancer screening,
• osteoporosis,
• hypertension,
• adult immunizations for flu and pneumonia.

Initially, all the HealthTexas practice audits were performed by practice administrative staff, but HealthTexas later enlisted KDJ Consultants to continue the APHS study on a contract basis.

KDJ Consultants began working with HealthTexas in 1997 and had a proven track record of success with their Credentialing department. Upon review of the APHS data abstraction process, the Best Care Committee recommended that HealthTexas use KDJ nurses to abstract data for the APHS audits. All KDJ nurses were trained on HealthTexas APHS guidelines by the HealthTexas Director of Clinical Excellence. Inter-rater Reliability (IRR) was completed to validate the nurses’ training and understanding of the study guidelines.

A new flow sheet was created and attached to every medical chart. It reminded physicians, nurses, and office staff to check on the need for preventative services at each patient visit. With the flow sheet in place, the APHS audit was repeated on 50 records. Following the audit, the data was reviewed and significant improvement in the results was seen.  It was found:

• The use of KDJ Registered Nurses rather than HealthTexas practice administrators improved the accuracy of the data collected and increased physician confidence in the results.
• KDJ nurses went beyond just abstraction and spent time with HealthTexas corporate staff and providers giving valuable insight regarding medical record content.
• Some improvement was attributed to the “Hawthorne Effect”, defined as the alteration of behavior by the subjects of a study due to their awareness of being observed.

Detailed guidelines for the APHS study were written and annual updates done, based on current preventive services literature and input from KDJ nurses. These guidelines and IRR results were reviewed annually by the Best Care Committee and given to the KDJ nurse reviewers as training updates.

HealthTexas and KDJ Consultants continued to monitor physicians’ quality scores but soon noticed that HealthTexas had reached a plateau, and quality scores were not improving.  After reviewing the data, they realized that APHS services could be improved by bringing a new focus on physicians getting patients to complete their recommended services. To accomplish this several interventions took place:

• Scoring methodology was updated so physicians received positive marks of “yes” or “done” ONLY if the patient actually got the service as recommended by the physician.
• “Recommended” and “refusal of services” were scored as a “no” or “not done”. Providers were advised to use every patient visit to address preventive services.
• HealthTexas unblinded the audit results for all clinics, creating a competitive environment.
• As questions arose regarding the validity of data at the clinic level, IRR was done with the care provider.  These one-on-one meetings became an opportunity to share new information with the care provider and build their trust.
• Rapid cycle improvement projects were initiated and resulted in the creation and distribution of tools and processes which were then shared across all HealthTexas clinics, facilitating further improvement in the delivery of preventive services.

As a result of this study and the ongoing education, HealthTexas providers improved their preventive health scores from the low of 57% to an average of 98%. This study continued for eleven years.

*Original article written by Chris Felton of HealthTexas and Kay Jones. Special article contributions from Barbara Hinds and Becky Headley.

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Traditional efforts to detect Adverse Events (“AEs”), events that result in patient harm, have focused on voluntary reporting and tracking of errors through incident reports or similar reporting. However, public health researchers have established that only 10 to 20 percent of such errors are ever reported and, of those, 90 to 95 percent cause no harm to patients (Griffin 2009). This data leads to one conclusion: hospitals need a more effective way to identify events that cause harm to patients and to select and test changes to reduce that harm.

In an effort to improve patient safety, KDJ Consultants was honored to assist Baylor Healthcare System based in Dallas, Texas with their Global Trigger Tool project, which identified triggers surrounding AEs to allow healthcare organizations to intervene prior to patient harm. The Global Trigger Tool project was expansive in both time and scope, as it extended over seven years and required review of a total of 18,091 charts.  Through their collaboration and use of the Institute for Healthcare Improvement (“IHI”) tool, KDJ Consultants and Baylor succeeded in the development of a training program for the Global Trigger Tool project which produced consistent and reliable results. Using this process, KDJ Consultants and its team of Registered Nurses reviewed patient medical records, abstracted AE data, and entered it into a software program written by the Baylor Healthcare Systems research department. Physicians at Baylor then reviewed a sample of these entries to ensure agreement with the results, which were then shared quarterly with the Baylor healthcare providers, the Board of Directors, and applicable quality committees of the hospitals. Results from this study allowed processes surrounding patient safety to be updated over time culminating in observable improvements across all study modules.

The Global Trigger Tool is used to identify AEs and measure the rate of AEs over time, including the following:

• Adverse Events per 1,000 Patient Days;
• Adverse Events per 100 Admissions; and
• Percent of Admissions with an Adverse Event

AE Triggers were grouped into six modules:

• Care Module
• Medication Module
• Surgical Module
• Intensive Care Module
• Perinatal Module
• Emergency Department Module

Collection of data into the database by module ultimately allowed for simplified high-level review of these events. As a result, the organization designed and implemented improved processes based on AEs more common to their organization, which in turn led to reduced incidence of AEs and improved overall patient safety.

Following the success of this initial effort, Deloitte Consulting contracted with KDJ Consultants to replicate this project for St. Joseph’s System in California, where 1,615 charts were reviewed across hospitals in that system with similar results.

For more information, go to https://www.ihi.org/search?keys=global+trigger+tool

Reference:  Griffin FA, Resar RK. IHI Global Trigger Tool for Measuring Adverse Events (Second Edition). IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2009. (Available at ihi.org)

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