The analytics of your rheumatology practice are more than just financial numbers, Owen Dahl said. Consider the time spent with patients, the percentage of cancellations recovered, your number of no-shows.
Second is to improve the quality of care by assessing patient performance on measurable health outcomes. “Is this patient,” for example, “doing better on this treatment, and do you have the documentation to support the decision to use this medication?” she asked.
Third is to move toward transparency on the total cost of healthcare. “Most of us talk about the total cost of care, but [most practices] don’t have that kind of transparency in our office,” she said. For example, practices don’t even receive the cost of medications from payers.
As it went about assessing what needed to be changed, the practice found that primary care providers were not adequately recognizing RA; they were making inappropriate referrals to rheumatologists; there was a lack of necessary records transferred after referral; there was no good system for e-referral; and there was poor communication between the primary care physician, the patient and the specialist to “close the referral loop,” Ms. Ferguson said.
Arthritis Northwest’s improvements involved measuring and eliminating the backlog of referrals by 76%, an increase of 43% in scheduled appointments involving inflammatory conditions and a decrease of 64 days—about an 80% change—in the number of days patients and providers have to wait before hearing from their office once a referral is received.
It has also begun offering expedited referrals through an e-referral system, which includes a screening questionnaire, and has developed protocols and tools for handling non-rheumatic disease diagnoses.
“Now, we’re seeing a lot more of the right patients at our practice,” Ms. Ferguson said.
Documentation has also been dramatically revamped, she said. Everything doctors decide is documented and aligned with guidelines. The clinical and financial picture is analyzed to give a total cost of care for the patient.
“This is really eye-opening for both the payer and our practice,” she said, and it allows them to try to reduce the cost of care together.
She offered these seven steps for defensive documentation:
- Tracking and monitoring the health status of specific patient groups;
- Documenting adherence to ACR guidelines;
- Documenting and reconciling medications;
- Documenting appropriate prevention screenings;
- Doing regular function and disease activity assessments;
- Documenting medical necessity; and
- Coding to the highest level of specificity.
Complying with Fraud & Abuse Laws
Jesse Overbay, JD, senior management consultant and general counsel at Doctors Management LLC, said practice managers and physicians should take seriously concerns about compliance with abuse and fraud regulations—particularly the Stark law and the anti-kickback statute.
The Stark law prohibits physicians from referring Medicare patients for certain health services to an entity with which they, or an immediate family member, has a financial relationship, unless an exception applies.
Intent to break the law is not required for a violation, and the law pertains only to physician referrals under Medicare. Penalties are civil and can include monetary penalties and liability under the False Claims Act.
The anti-kickback statute is criminal in nature and prohibits anyone from offering, paying, soliciting or receiving anything of value to induce or reward referrals or general federal healthcare program business. Under this statute, intent must be proved. Penalties include fines of up to $25,000 per violation and up to five years in prison per violation.
“If you google ‘false claims act’ [or] ‘anti-kickback,’ you’ll see headlines from the last few weeks, and definitely from the last few months, of providers—in some cases, practice managers [and] billers—going to jail for these types of violations,” said Mr. Overbay. “It’s something to definitely be aware of.”
The False Claims Act is violated when an individual or corporation—but not the federal government or a state agency—“presents or causes to be presented, a false or fraudulent claim.”
Mr. Overbay said there has been an uptick in whistleblower cases in recent years.
“People feel like they’re not being heard in their organization,” he said. “It goes back to compliance.”
Every practice, Mr. Overbay stressed, needs a compliance program. If a practice has to undergo a federal audit and doesn’t have one, it will often be put under a “corporate integrity agreement (CIA)” led by federal overseers.
“It’s like a compliance program on steroids,” Mr. Overbay said. “They’re running it. They monitor it. … You do not want to be under a corporate integrity agreement.”
He outlined seven elements of a successful compliance program:
