Financial Resource Management
Goals of quality reporting systems in healthcare organisations
Aims of Reporting Systems
Better care – improving quality of care by making it more patient centered,
reliable, accessible and safe
Improving population health by studying statistics and recommending any
Reducing healthcare costs – ensure efficiency of systems and reduce
Goals of reporting systems
Making care safer by reducing harm caused in the delivery of care
Ensuring that each patient and family are engaged as partners in their care
Promoting effective communication and coordination of care
Promoting the most effective prevention and treatment practices for the
leading causes of mortality
Working with communities to promote wide use of best practices for
Making quality care more affordable for individuals, families, employers,
and governments by developing and spreading new healthcare delivery
Quality system models currently used
PQRS(Physician Quality Reporting System)
is a pay-for-reporting program that gives eligible professionals incentives
and payment adjustments if they report quality measures satisfactorily.
The quality measures vary from year to year but include care coordination,
patient safety and engagement, clinical process/effectiveness, and
PQRS Group Practice Reporting Option (GPRO)
It is part of the above and is a program that encourages eligible group
practices to report information about the quality of the care they provide to
people with Medicare who have certain medical conditions.
Quality system models currently used ……contd
Electronic Prescribing (eRx) Incentive Program
The eRx Incentive Program is a pay-for-reporting program that encourages
physicians and other healthcare professionals to use electronic prescribing to
improve communication, increase accuracy, and reduce errors.
EHR Incentive Program
The Electronic Health Records (EHR) Incentive Program provides incentives
and payment adjustments to eligible professionals who use certified EHR
technology in ways that may improve healthcare
the Medicare Shared Savings Program
Value-based Payment Modifier. The Value Modifier provides for differential
payment to a physician or group of physicians
under the Medicare Physician Fee Schedule based upon the quality of care
furnished compared to cost during a performance period.
Advantages and disadvantages of quality reporting systems
better Record management for both patients & reduced paperwork for
Rigidity – one way of doing things thus prevents innovation
Expensive – costs of maintaining & implementing systems are high
Role of HIIM staff participating in value based purchasing
As health care providers normally determine the quality and cost of the
health care services they provide
VBP was introduced to reward providing “value” service as opposed to
volume as was the case before.
Value means providing service that take into account cost savings, good
patient experience, reporting transparency etc
HIIM staff’s role is to participate in improving the healthcare system by
filling VBP forms.
False Claims Act
The False Claim Act is a federal law that makes it a crime for any person or
organization to knowingly make a false record or file a false claim
regarding any federal health care program, which includes any plan or
program that provides health benefits, whether directly, through insurance
or otherwise, which is funded directly, in whole or in part, by the United
States Government or any state healthcare system. Knowingly includes
having actual knowledge that a claim is false or acting with “reckless
disregard” as to whether a claim is false.
False Claims Act and Health care providers
Examples of Frauds
Ghost Patients: The submission of a claim for health care services to a
patient who either does not exist or who never received the service.
Kickbacks: The federal Anti-Kickback Statute prohibits any offer,
payment, solicitation or receipt of money, property or remuneration to
induce or reward the referral of patients or healthcare services payable by a
government health care program, including Medicare or Medicaid.
Up-Coding Services: submitting of a claim for health care services,
treatments, diagnostic tests or items which represent a more serious and
more expensive procedure than that which actually was performed.
Up-coding can be a violation of the Federal False Claims Act.
Inflating Cost Reports: One common type of fraud has been for hospitals
to inflate or falsify medical cost reports to maximize its reimbursement
Research Grant Fraud: these include falsifying research data, over-billing
for research expenses & using grand money on other things.
Criminal disclosure provision of the Social Security Act.
In a qui tam suit under the False Claims Act, a private party (relator) can
file a case against a defendant alleging fraudulent activities against the
Whistle blowers protection – any employee of the government who reveals
key information to government on possible fraud actions will be given
It prohibits certain business activities that federal government regulators deem
to be anticompetitive, and requires the federal government to investigate
and pursue trusts, companies, and organizations suspected of being in
It’s a federal law enacted as an amendment to the Sherman Anti-trust
Act prohibiting undue restriction of trade and commerce by designated
Federal Trade Commission Act
This established the Federal Trade Commission which was authorized to
issue “cease and desist” orders to large corporations to curb unfair trade
practices such as deceptive advertisements and pricing
Importance of laws /Acts to health care providers
The Federal Trade Commission is a law enforcer that ensures fair play is
maintained in the health sector.
The Sherman & Clayton acts provide protection from unfair competition by
cartels and other large groups.
Stark II statute
This prohibits a healthcare provider from submitting Medicare claims for
payment based on patient referrals from physicians having an improper
financial relationship (as defined in the statute) with the hospital.
It prohibits any offer, payment, solicitation or receipt of money, property or
remuneration to induce or reward the referral of patients or healthcare
services payable by a government health care program.
Importance to healthcare providers
The Medicare and Medicaid Patient Protection Act of 1987 was created as
an amendment of certain sections of the social security act to improve the
antifraud provisions relating to those programs. It contains the above