Curbing overutilization: the silver lining to HCFA compliance.Sometimes you have to make people an offer they can't refuse. The threat of liability for Medicare noncompliance noncompliance
failure of the owner to follow instructions, particularly in administering medication as prescribed; a cause of a less than expected response to treatment.
noncompliance helped one institution finally rein in redundant bedside testing.
Thanks to recent legislation,[1,2] laboratory managers have become aware of their potential legal liability for inappropriate test utilization. That became clear when the Office of the Inspector General Office of the Inspector General (or OIG) is a common sub-agency within cabinet-level agencies of the United States federal government and serves as auditing and investigative arm of the agency's programs focused on identifying waste, fraud and abuse. for the Health Care Financing Administration Health Care Financing Administration,
n.pr department in the U.S. agency of Health and Human Services responsible for the oversight of the Medicaid and Medicare benefit programs, including guidelines, payment, and coverage policies. promulgated prom·ul·gate
tr.v. prom·ul·gat·ed, prom·ul·gat·ing, prom·ul·gates
1. To make known (a decree, for example) by public declaration; announce officially. See Synonyms at announce.
2. the Model Laboratory Compliance Plan under the Medicare Integrity Program. But there is a potential benefit from this heavy regulatory. burden. The need for hospital-wide corporate compliance can be used to control inappropriate laboratory utilization - a useful tool, instead of a sword hanging over our heads. Clinicians who have remained indifferent to utilization control and cost containment cost containment,
n the features of a dental benefits program or of the administration of the program designed to reduce or eliminate certain charges to the plan. become much more interested when the issues are couched in terms of Medicare fraud Medicare fraud Medifraud Medical practice Any unlawful act which results in the inappropriate billing of Medicare for services by a health care provider–eg, physicians, hospitals and affiliated providers. See Medicare. . We leveraged our institution's development of a HCFA HCFA
Health Care Financing Administration
n.pr See Health Care Financing Administration. compliance plan against the overuse overuse Health care The common use of a particular intervention even when the benefits of the intervention don't justify the potential harm or cost–eg, prescribing antibiotics for a probable viral URI. Cf Misuse, Underuse. of a common form of bedside testing, with results that saved thousands of dollars a year.
The University of Alabama at Birmingham UAB began in 1936 as the Birmingham Extension Center of the University of Alabama. Because of the rapid growth of the Birmingham area, it was decided that an extension program for students who had difficulties which prevented them from studying in Tuscaloosa was needed. Health System includes the University of Alabama The University of Alabama (also known as Alabama, UA or colloquially as 'Bama) is a public coeducational university located in Tuscaloosa, Alabama, USA. Founded in 1831, UA is the flagship campus of the University of Alabama System. Hospital, a variety of outpatient clinics, home health services, and an outreach laboratory serving healthcare providers in central Alabama. The Department of pathology and UAB Hospital Laboratories developed a compliance plan that conformed to the OIG Noun 1. OIG - the investigative arm of the Federal Trade Commission
Office of Inspector General
independent agency - an agency of the United States government that is created by an act of Congress and is independent of the executive departments model. This plan establishes clear lines of communication "Lines of Communication" is an episode from the fourth season of the science-fiction television series Babylon 5. Synopsis
Franklin and Marcus attempt to persuade the Mars resistance to assist Sheridan in opposing President Clark. , identifies departmental roles in compliance monitoring, and ties the hospital laboratories to the UAB UAB Universitat Autònoma de Barcelona
UAB University of Alabama at Birmingham
UAB Union of Arab Banks
UAB Uzdaroji Akcine Bendrove (Lithuanian: closed stock company
UAB Unix AppleTalk Bridge
UAB Unaccompanied Air Baggage
UAB Until Advised By Health System's corporate compliance office.
Test orders and billing records generated in various laboratories are forwarded to the laboratory information system (LIS LIS - Langage Implementation Systeme.
A predecessor of Ada developed by Ichbiah in 1973. It was influenced by Pascal's data structures and Sue's control structures. A type declaration can have a low-level implementation specification. ). The LIS provides data used to generate reports on compliance for laboratory administrators and section heads. Reported parameters include information on appropriate diagnosis coding, proper bundling of tests in approved panels, and specific requirements for individual laboratories. When laboratory processes are found to be in compliance, section heads forward compliance tracking reports to the compliance office. When compliance problems are identified, the section head notifies the division director, develops and implements an action plan to address the problem, and files a noncompliance tracking report with the compliance office.
Most of the laboratory's compliance effort has focused on outpatient coding and billing, but the laboratory administration has examined inpatient testing as well, starting with bedside testing for glucose, blood gases, and electrolytes. Several critical care areas at UAB use i-STAT portable clinical analyzers (i-STAT Corp., Princeton, NJ) for glucose, blood gases and/or electrolyte testing. We took a closer look at how bedside testing was being used, and how far inappropriate utilization could be curbed in the context of corporate compliance.
Several of UAB's key clinical centers made extensive use of the i-STAT 6+ panel (sodium, potassium, chloride, urea nitrogen, glucose, and hematocrit Hematocrit Definition
The hematocrit measures how much space in the blood is occupied by red blood cells. It is useful when evaluating a person for anemia.
Blood is made up of red and white blood cells, and plasma. ), including the neurosciences intensive care unit (NICU NICU
neonatal intensive-care unit ), the coronary care unit coronary care unit
Abbr. CCU A hospital unit that is specially equipped to treat and monitor patients with serious heart conditions, such as coronary thrombosis. (CCU CCU
1. coronary care unit
2. critical care unit
critical care unit.
CCU Critical care unit, see there ), and the heart transplant intensive care unit (HTICU). A review of LIS records revealed a significant duplication rate for both 6+ panels and fluid balance profiles (sodium, potassium, chloride, bicarbonate, anion gap, glucose, urea nitrogen, and creatinine) from the core laboratory. We defined duplication as a fluid balance profile and a 6+ panel run within 1 hour of each other. Our initial survey in October 1997 found duplication rates of 32% in CCU, 54% in HTICU, and 49% in NICU.
After interviewing nurses about possible reasons for this redundant testing, we developed and distributed a survey to determine which reasons were most commonly offered (see Table). Only a minority of nurses explicitly said that they distrusted bedside results, but more indicated that physician distrust was a factor - and the overwhelming majority felt the need to verify abnormal bedside analyzer values with core laboratory tests. The next two most frequent responses - follow-up after treatment or a change in the patient's condition - meet the criteria for medically necessary testing.
Delivering the message
We arranged a series of meetings with nurse managers, staff nurses, and attending and resident physicians to discuss corporate compliance and utilization. Where applicable, we presented evidence of the reliability of bedside testing results. However, we emphasized the need to choose the most appropriate testing methods and limit duplicate testing to conform to the criterion of medical necessity. When bedside testing values were abnormal, we advised the nurses not to automatically order a follow-up test from the core laboratory in anticipation of the physician's response. Then we presented physicians with clear test ordering options that eliminated unintended coincidental orders. As these interventions came on line, we kept a close eye on utilization patterns.
Table Why run redundant tests? In a survey, nurses were asked why a six-test panel on a bedside analyzer was run concurrently with a similar profile in the core laboratory. Here are the results: Check validity of abnormal analyzer result 75.8% Follow up on a change in patient's condition 57.9% Physicians do not trust analyzer results 50.5% Coinciding orders 50.5% Follow up after treatment 48.4% I do not trust analyzer results 15.8% Convenience 6.3%
The effort paid off, as the Figure illustrates. Predictably, some improvement occurred as soon as attention was drawn to the issue (the Hawthorne effect). But improvements continued in all units, with duplicative testing declining to 18% in CCU, 21% in HTICU, and 15% in NICU. The reward for this greater control was significant cost containment. When routine fluid balance profiles were run alone, instead of being paired with i-STAT 6+ panels, the reduced use of i-STAT cartridges generated a savings of $1,500 per month in supply costs alone.
A zero duplication rate was never a goal of the program. When a patient's condition is highly unstable, or when the effects of treatment require close monitoring, multiple laboratory tests may be medically necessary. Needless testing, on the other hand, provides no benefit and actually may pose risk to patients, in addition to consuming scarce medical resources. Laboratory managers must comply with DIG guidelines or risk severe consequences; those who exploit the opportunity provided by this requirement can gain a tool to trim inappropriate utilization of laboratory services.
1. Public Law: 104-191, Health Insurance Portability and Accountability Act The Health Insurance Portability and Accountability Act (HIPAA) was enacted by the U.S. Congress in 1996.
According to the Centers for Medicare and Medicaid Services (CMS) website, Title I of HIPAA protects health insurance coverage for workers and their families when of 1996. http://thomas.loc.gov/cgi-bin/bdquery/z?d104: h.r.03103:. Accessed 7/23/98.
2. Public Law 105-33, The Balanced Budget Act of 1997. 105th Congress of the U.S. http://thomas.loc.gov/cgi-bin/bdquery/z?d105: h.r.02015:. Accessed 9/4/97. Government Printing Office: Washington DC; 1997.
3. Health Care Financing Administration, Office of the Inspector General. The Medicare Integrity Program. http://www.hcfa.gov/medicare/mip/default.htm. Accessed 7/23/98.
Meredith Kilgore is a doctoral fellow at the RAND Graduate School in Santa Monica, CA. LuAnn Hensley and Carol Howard are bedside testing coordinators, and Jennie Craft is director of hospital laboratories, all with the University of Alabama Hospital in Birmingham. John Smith is professor and director, laboratory medicine division, department of pathology, University of Alabama at Birmingham.