At the Health Care Compliance Association’s (HCCA) Compliance Institute in May, quality of care presentations covered issues such as correct use of data, board education, and government enforcement.

The presenters’ message was clear: Quality is quickly becoming an integral component of reimbursement, and it needs to be incorporated into your existing compliance programs.

“CMS has adopted a new strategy, and that is to transform itself into an active purchaser of quality,” says Janice Anderson, a partner at Foley & Lardner in Chicago and an HCCA presenter. “That strategy will include payment reform, public reporting, and enforcement. We’re moving to pay for performance, which is value-based, and future payment will be based on quality.”

Using readmission data

CMS has identified hospital readmissions as one target area. Therefore, providers need to carefully monitor readmission data for potential quality of care and billing issues, says Kimberly Hrehor, project director of the hospital payment monitoring program at the Quality Improvement Organization Support Center.

Hrehor was one of several presenters at an April HCCA panel session, “In Pursuit of Quality: Let the Data Be the Driver.” She advised attendees on how to effectively evaluate their readmissions.

It’s a timely topic, Hrehor says. In a 2007 report to Congress, MedPac determined that approximately 17% of Medicare patients are rehospitalized within 30 days, and 76% of those readmissions were preventable.

“Readmissions can be a definite indicator of quality, and [quality improvement organizations] will be working with hospitals to reduce them,” Hrehor says.

First, hospitals should generate a case listing by looking at readmissions during a given time period, she says. Using that case listing, they can identify patients potentially readmitted due to premature discharge on first admission and can see any billing errors from that first visit.

“They can also identify possible times when a patient was readmitted for care that should have been provided during the first visit,” Hrehor adds. When looking at readmission data, pay special attention to the condition code B4, she says.

Medicare allows the use of B4 when a patient is discharged from an acute care hospital and is readmitted on the same day for an unrelated condition. The code cannot be used for evaluation and management services related to the earlier condition, and the code must be submitted to receive payment for the two separate DRGs, Hreror says.

“We did an analysis looking at the assignment of B4, and we found that, in about 7% of cases, the readmission DRG is the same as the original, so they couldn’t be unrelated,” Hreror says. “Also, about 13% of cases were probably related because the readmission DRG was for complications such as infection related to the original condition.”

The incorrect application of B4 represents a compliance risk for hospitals. The best approach to this issue is to run a query on all claims assigned B4 and look for basic information on those claims, Hrehor says. For example, principal diagnosis codes and status codes can give clues as to whether the condition code is being used properly. And if something doesn’t make sense, pull the record and speak to the people involved, she says.

“Auditors need to have a definite process that they use to ascertain if the first and second visits are unrelated,” Hrehor says.

Getting the board involved

Auditors can’t be successful in monitoring quality if they don’t have the support of the board and other leadership in the hospital, says Kathy Roberts, corporate compliance and privacy officer at Baptist Health in Little Rock, AR. Roberts, another presenter at the “In Pursuit of Quality: Let the Data Be the Driver” session, shared ways to meld communities within a hospital and demonstrated the importance of good quality-of-care data.

First, Roberts presented three simple auditing scenarios that she shared with her board to show the relationship between compliance and quality. The first audit was of Baptist Health’s peripherally inserted central catheter line protocol. Roberts explained how the audit showed whether specifically trained nurses were complying with set practices.

In the second audit, Roberts highlighted the issue of medical necessity for admission into an inpatient rehabilitation facility. Finally, she discussed an audit of the medical necessity of cataract surgery.

“The biggest issue that I see right now is ensuring that your leadership is clear on why quality is so important. So many areas of the hospital function in silos and meet independently, and they need to be able to work together,” she says.

As long as providers are looking at billing and conditions of participation without integrating quality into the equation, auditing for quality will be problematic, Roberts adds.

It can be overwhelming, she says, so begin by looking at issues of medical necessity and bringing these cases to your board’s attention.

Changing enforcement

Auditing for quality of care should also be high on your list. The government’s enforcement of quality of care is becoming increasingly creative, such as CMS’ new strategies and value-based purchasing, says Anderson.

“In order to enforce quality, CMS has had to come up with legal strategies that tie it to payment,” she says.

For example, according to CMS, submitting a claim is now the same as certifying that the condition on the claim is medically necessary. Further, it asserts that the claim meets the requirements for payment, thus opening the door for use of the False Claims Act if those conditions are not met, says Anderson.

In addition, by submitting a claim, hospitals implicitly state that they meet the conditions of participation under new enforcement.

These new interpretations are examples of CMS’ attempt to bootstrap quality to payment, and providers need to be aware of them, Anderson says, adding that “just like billing and physicians’ financial relationships, quality is emerging as a number one compliance issue.”

Tip: Inject quality control into work flow rather than look at it retrospectively

Instead of poring over old data, collect data and put in mechanisms so measures can be captured at the point of care. For example, a form may be able to capture laboratory values, potential drug interactions, and vital signs necessary for reporting.

This process is made much easier with a fully functioning electronic health record, but it can still be feasible for facilities without one.

Tip: Actively audit quality

Quality needs to be integrated completely within a hospital’s compliance program and audited regularly. Most importantly, the board needs to understand that payment and performance are now inextricably linked, says Janice Anderson, a partner at Foley & Lardner in Chicago.

“It sounds simple, but that’s really our biggest recommendation,” Anderson says. “Providers need to look at where they might be having breakdowns and then try to fix those problems proactively before anything happens.”