Lyles, Mark A. MD, MBA
Program integrity (PI) is defined as a comprehensive strategy to prevent fraud, abuse, errors, and waste in our nation’s health care system. PI has the goal of eliminating improper payments for health care services. The article by Agrawal and colleagues1 in this issue of Academic Medicine presents an excellent overview of the concerted efforts by the Centers for Medicare and Medicaid Services (CMS) and other payers to ensure the integrity of our nation’s public and private health care reimbursement systems. The authors detail cogent reasons and methods to increase physicians’ and other providers’awareness of PI, and they propose numerous reasons why, and waysby which, physicians and physicians-in-training can be better educated about this increasingly important topic. This commentary will review current challenges to educating physicians and physicians-in-training about PI, and it will explore a PI education curriculum already in place at a large academic medical center that might serve as a model for other institutions.
PI on a National Level
As Agrawal and colleagues detail, in 2012, the U.S. federal government announced a record recovery of $4.1 billion in improper payments by CMS programs. This amount, while representing a nearly fourfold increase over the amount recovered in 2008, represents less than one-half of 1% of the improper payments thought to be made annually by CMS and other payers. The Institute of Medicine (IOM) estimated that the U.S. health care system annually loses almost $765 billion to “waste.”2 This $765 billion includes an estimated $210 billion in improper reimbursements for unnecessary services, $190 billion in excess administrative costs, $130 billion in inefficiently delivered services, $105 billion in egregious pricing of services, $75 billion in fraud, and $55 billion in missed prevention opportunities. Given that the United States spent in excess of $2.7 trillion on health care services in 2012, this $765 billion in waste suggests that almost 1 of every 3.5 dollars spent this past year was unnecessarily reimbursed. Numbers of this magnitude necessitate that we provide better PI education for physicians and physicians-in-training.
Egregious examples of fraud and abuse can be readily and universally categorized as actual instances of fraud and abuse, and efforts to prevent such schemes should be prioritized. As detailed by Agrawal and colleagues, a recent example of fraud is the physician, pharmacist, and others in California who repeatedly billed Medicare and Medi-Cal for the same pills over and over again.3 Another recent example is the mental health care providers in Florida who paid kickbacks to operators of assisted living facilities and halfway houses in exchange for delivering patients to sham treatment programs.4 These providers were reimbursed inappropriately in excess of $200 million for these fraudulent claims.
On the other end of the spectrum of PI issues are common, everyday examples of administrative mistakes and errors that, most often, are not intentional—lack of proper documentation to support medical necessity, misunderstandings regarding what is and what is not required for appropriate documentation in the medical record, and unintentional misclassification of a diagnosis or procedure. These types of fraud and abuse can occur quite frequently but most often are unintentional.
Educating Physicians About PI
As suggested by Agrawal and colleagues, all health care providers, including physicians and physicians-in-training, need to be better educated about the numerous aspects of PI. Egregious examples of fraud and abuse are relatively easy to explain and teach to physicians, and the administrative oversights and mistakes that commonly occur can be rectified by standardizing and better teaching the billing rules and documentation requirements physicians must follow to be reimbursed for providing health care services. Addressing these extremes will require considerable resources and education, yet we can do so with relative ease.
However, the more ambiguous areas of PI, the vast middle ground between these polar ends of the PI spectrum, will likely remain more difficult to address, at least for the foreseeable future. These more ambiguous areas of fraud and abuse—categorized by Agrawal and colleagues and the IOM as improper reimbursements for unnecessary services, excess administrative costs, inefficiently delivered services, egregious pricing of services, and missed prevention opportunities—are often difficult to define and to understand, thereby making PI education on these topics more challenging to implement effectively and to teach to physicians and physicians-in-training. However, these more ambiguous areas of PI represent the greatest amount of estimated waste in our health care system. We then must first better define all of the categories and items that fall into this “gray zone” of PI before we design educational programs to teach physicians and other providers how to avoid committing such infractions.
As our nation wrestles with the latest episode of health reform, providers and payers are reminded daily of the current inefficiencies and inconsistencies under which our nation’s disparate reimbursement systems operate—rules and regulations vary considerably from payer to payer, medical necessity guidelines and requirements are often vague or poorly understood, and the reimbursement and clinical documentation guidelines are always evolving. Additionally, state-specific rules and regulations often add requirements and administrative procedures that can vary considerably between states and even between an individual state’s disparate programs. These inconsistencies make it increasingly difficult for compliance officers, coders, and administrators to craft and deliver a common educational effort to teach physicians and other providers about the myriad aspects of PI. Until our nation adopts consistent and universal methods for documenting, billing, and reimbursing for health care services, it will remain extremely difficult to educate providers and to ensure their compliance with the more ambiguous aspects of PI.
Given the slowness with which health policy reforms historically have been adopted within the United States, and the current polarization of political viewpoints regarding how our nation’s health care system should best be reformed, it is likely that we will remain in this awkward reimbursement and regulatory limbo for at least the foreseeable future. Therefore, it will become increasingly important for physicians, payers, policy makers, product makers, and patients to collaborate and to collectively define and minimize waste in our health care system. These partners also will need to define common rules, regulations, and guidelines that can be explained and followed consistently. Until this is accomplished, educating providers about PI will remain challenging. Even without these changes, egregious instances of fraud and abuse will continue to be recognized with relative ease and punished appropriately, and the unintentional administrative oversights will continue to be refined and addressed, yet the PI issues that fall into the “gray areas” will continue to exist, and their incidence will likely even increase.
Curriculum Suggestions: Teaching Physicians About PI
While our country remains in thisstate of PI limbo, many successful examples of ways to educate physicians and other providers about PI already exist. We should examine, improve, and promulgate these successful efforts throughout the nation’s existing health care and educational settings.
Agrawal and colleagues suggest that the current methods of educating medical professionals about PI do not include sufficient emphasis on fraud awareness or best practices for ensuring proper payments. Rather than debating the definition of “sufficient” emphasis, defining the ideal methods to increase providers’ understanding of, and compliance with, all aspects of PI is more important.
Since 2000, the Medical University of South Carolina (MUSC) has used an educational model to teach physicians and physicians-in-training about PI. While this real-world example of PI education has evolved considerably over time and annually undergoes refinement, it has the potential to serve as a model curriculum for academic medical centers that do not yet have formal PI education programs in place.
MUSC has long required that PI education programs target physicians and providers-in-training.5 Currently, this education requires all new and existing staff physicians to understand and comply with policies and procedures for billing appropriately for all services rendered. Additionally, it includes didactic and computer-based sessions on the False Claims Act, conflict of interest/drug company relationships, Health Insurance Portability and Accountability Act privacy and security, Stark and antikickback statutes, Medicare audit activity, teaching physician regulations, and evaluation and management/specialty-specific coding rules. MUSC physicians are taught the importance of securely storing and using their National Provider Identifications and why and how to report improper activities.
Agrawal and colleagues are correct in their conclusion that efforts to educate both medical school faculty and physicians-in-training have synergistic effects. Programs that ensure physician faculty members understand and follow PI rules and guidelines also benefit their trainees who observe and follow the standards and behaviors set forth by their superiors. Likewise, trainees who are well-versed in PI can ensure that inadvertent or intentional instances of violating PI standards can be readily addressed.
With regard to educating residents, before beginning their clinical training, each resident at MUSC must undergo a compliance and billing orientation.6 Educators explain and discuss multiple examples of fraud and abuse, including inappropriate resident supervision, inaccurate coding, duplicate billing, and up-coding. Given the U.S. health care system’s increasing reliance on electronic medical records to document and bill for medical services, residents also are taught the documentation rules and regulations regarding inappropriately copying and pasting and up-coding for medical services. Next, compliance staff educate residents about the implications of committing fraud and abuse and review in depth the resulting financial and criminal penalties.
In addition, MUSC residents are taught how to document appropriately in the medical record and why they must do so clearly and legibly. Educators also explain to residents and faculty why and how they must adequately describe and document the services they are providing, and all physicians and physicians-in-training are taught how, and why, clinical documentation must meet the guidelines established by payers, the Joint Commission, and/or the American Medical Association’s Current Procedural Terminology definitions. Finally, educators emphasize the importance of documenting, signing, and dating medical records within defined time limits.
In addition to completing the required curriculum in coding and billing compliance, each resident at MUSC is taught the importance of minimizing conflicts of interest; adhering to Stark laws, anti-kickback statutes, Civil Monetary Penalties legislation, and numerous state-specific rules and regulations; understanding and following medical necessity guidelines; protecting one’s medical identity; and following the university’s code of conduct. Although MUSC is proud of its successful efforts to better educate its physicians and physicians-in-training about PI, the university is well aware that opportunities exist to enhance and refine its existing educational paradigm. Agrawal and colleagues are correct that further emphasis on PI should, and must, be provided to health professionals from the onset of their training. Medical and other health care professionals at MUSC increasingly are beginning their PI education before they even document in medical records or bill for professional services. Efforts to standardize this type of education should be shared and used nationwide at all medical education sites.
Finally, all PI education programs must be both comprehensive and progressive, and they also must be responsive and readily adaptable to the increasing number of rules, regulations, and policies being adopted and promoted by governmental payers, private payers, policy makers, and legislators. Adherence to national laws, guidelines, and regulations, as well as to the increasing number of local and state-specific rules and regulations, also must be addressed.
The current efforts by CMS to eliminate improper payments should, and must, continue. Yet, for the foreseeable future, educating U.S. physicians and other health care professionals about the many evolving aspects of PI will remain challenging. While we can define egregious examples of fraud and abuse relatively easily, universally accepted definitions of “waste” and “improper payment” remain elusive. Until all payers and providers can reach a consensus regarding these definitions, eliminating waste from the U.S. health care system will remain difficult.
Other disclosures: None.
Ethical approval: Not applicable.
Previous presentations: Information about the Medical University of South Carolina (MUSC) program integrity (PI) education curriculum was presented at multiple compliance, Health Insurance Portability and Accountability Act training, and PI education sessions held at MUSC.