Identifying barriers to billing compliance

Programs designed toward the control of health care fraud are leading to increasingly aggressive enforcement and prosecutorial efforts by federal regulators, related to over-reimbursement for service providers. Greater penalties for fraudulent practices have been touted as an effective deterrent to practices that encourage, or fail to prevent, incorrect claims for reimbursement. In such a context, this study sought to examine the extent of compliance management barriers through a national survey of all accredited US health information managers, examining likely barriers to payment of health care claims. Using data from a series of surveys on the stated compliance actions of more than 16,000 health care managers, we find that the publication and dissemination of compliance enforcement regulations had a significant effect on the reduction of fraud. Results further suggest that significant non-adoption of proper billing compliance measures continues to occur, despite the existence of counter-fraud prosecution risk designed to enforce proper compliance. Finally, we identify benchmarks of compliance management and show how they vary across demographic, practice setting, and market characteristics. We find significant variation in influence across practice settings and managed care markets. While greater publicity related to proper billing procedures generally leads to greater compliance awareness, this trend may have created pockets of "institutional non-compliance," which result in an increase in the prevalence of non-compliant management actions. As a more general proposition, we find that it is not sufficient to consider compliance actions independent of institutional or industry-wide influences.     

Factors influencing the costs of workers' compensation

This article presents several factors believed to have shaped the costs of workers' compensation. Of these factors, the most notable influence on claims severity is related to the way medical care is delivered to treat occupational injuries and illnesses. Although medical care providers may have some influence on the other factors responsible for increased claims severity, such as attorney costs and differences in state workers' compensation laws, they have a tremendous impact on the way medical care is delivered and its resultant costs. This places physicians, nurse practitioners,physical therapists, chiropractors, nurses, and physician assistants in a unique role of being able to assist US business in improving productivity through a reduction in workers' compensation costs.     

Are you committing health care fraud under the False Claims Act? The answer may not be as simple as you think

Health care fraud has a significant financial effect on the operations of the American health care system. Governments and insurers are intent on quashing such fraud and have instituted massive efforts to indict and punish offenders as well as recover major monetary awards. This article provides examples of fraudulent practices and details the definitions of fraud and abuse. In addition, it characterizes the concept of qui tam that allows whistleblowers to share in any financial awards. Finally, it highlights the importance of proper coding as a means of reducing the suspicion of fraud or abuse.     

A survey on statistical methods for health care fraud detection

Fraud and abuse have led to significant additional expense in the health care system of the United States. This paper aims to provide a comprehensive survey of the statistical methods applied to health care fraud detection, with focuses on classifying fraudulent behaviors, identifying the major sources and characteristics of the data based on which fraud detection has been conducted, discussing the key steps in data preprocessing, as well as summarizing, categorizing, and comparing statistical fraud detection methods. Based on this survey, some discussion is provided about what has been lacking or under-addressed in the existing research, with the purpose of pinpointing some future research directions.     

Barriers to workers' compensation and medical care for injured Personal Assistance Services workers

OBJECTIVES: We documented barriers to workers' compensation and injury-related medical care faced by homecare or Personal Assistance Services (PAS) workers. We explored differences between independent providers and agency-employed workers. METHODS: We conducted in-depth, semi-structured interviews with a diverse sample of 38 injured workers. Participants were primarily female and racial-ethnic minorities. RESULTS: Most participants (82%) were independent providers. Common barriers to reporting injury included commitments to clients and financial pressure. Unlike agency employees, many independent providers knew little about workers' compensation eligibility and injury reporting procedures, and frequently were given "the runaround" by the social service bureaucracy when they attempted to report injury and access injury-related medical care. Among independent providers, delays in filing a claim and receiving timely medical attention were common. CONCLUSIONS: The lack of a traditional employment infrastructure has important implications for vulnerable workers' health and the sustainability of consumer-directed PAS programs. We provide recommendations for improving workers' access to workers' compensation and injury-related medical care.     

Workers' compensation reform in New York State: A proposal to address medical,ergonomic, and psychological factors associated with work disability

This paper presents testimony before the New York State Assembly Joint Hearings on Workers' Compensation. The testimony first establishes the background of the speaker in relation to the problems in the workers' compensation system. A brief summary of the problem including the increased prevalence of work-related musculoskeletal disorders and their contribution to work disability, the rising costs of insurance premiums, indemnity, and medical costs, and the percentage of payroll that workers' compensation costs consume in New York State is then presented. A review of problems injured workers and health care providers face is also considered. Following this, two proposals that represent a compromise position in relation to business and labor concerns are presented. The first relates to the implementation of state mandated prevention programs to reduce the risk of injury/illness and associated disability in areas accounting for the majority of the workers' compensation injuries/illnesses—low back and upper extremity disorders. It is proposed that individual employers receive incentives in the form of premium savings based upon actual program outcomes. The second proposal relates to the establishment of mutually agreed upon standards of health care for low back and upper extremity disorders similar to what currently exists in Minnesota. The potential benefits of these plans are discussed in relation to increasing costs and human suffering associated with work-related injuries/illness and disability. This paper is presented as an example of an approach to advocacy that health care providers can take to contribute to reform in the workers' compensation systems of their own states.     

Dishonesty in health care practice: A behavioral experiment on upcoding in neonatology

Dishonest behavior significantly increases the cost of medical care provision. Upcoding of patients is a common form of fraud to attract higher reimbursements. Imposing audit mechanisms including fines to curtail upcoding is widely discussed among health care policy‐makers. How audits and fines affect individual health care providers' behavior is empirically not well understood. To provide new evidence on fraudulent behavior in health care, we analyze the effect of a random audit including fines on individuals' honesty by means of a novel controlled behavioral experiment framed in a neonatal care context. Prevalent dishonest behavior declines significantly when audits and fines are introduced. The effect is driven by a reduction in upcoding when being detectable. Yet upcoding increases when not being detectable as fraudulent. We find evidence that individual characteristics (gender, medical background, and integrity) are related to dishonest behavior. Policy implications are discussed.     

Workers' compensation costs: still a challenge

The workers' compensation system in the United States, comprised of independent state based and national programs for federal workers, covers approximately 127 million workers and has evolved and grown since its inception in 1911. Coverage has significantly broadened in scope to allow for the inclusion of most occupational injuries and illnesses. The cost of workers' compensation care has also increased. Some of the cost drivers have been identified,and various approaches have been taken to address medical cost containment. There is a need to balance cost control with ensuring benefit adequacy and quality of medical care. It is likely that managing workers' compensation costs will continue to be a challenge in the foreseeable future. The cost of workers' compensation care affects all stakeholders including workers, employers,providers, state workers' compensation regulators, legislatures,and insurers. A continued commitment to quality, accessibility to care, and cost containment, and being alert to emerging issues that can affect these elements, will help ensure that workers are afforded accessible, high quality, and cost-effective care.     

How liability law affects medical productivity

Previous research suggests that "direct" reforms to the liability system-reforms designed to reduce the level of compensation to potential claimants-reduce medical expenditures without important consequences for patient health outcomes. We extend this research by identifying the mechanisms through which reforms affect the behavior of health care providers. Although we find that direct reforms improve medical productivity primarily by reducing malpractice claims rates and compensation conditional on a claim, our results suggest that other policies that reduce the time spent and the amount of conflict involved in defending against a claim can also reduce defensive practices substantially. In addition, we find that "malpractice pressure" has a more significant impact on diagnostic rather than therapeutic treatment decisions. Our results provide an empirical foundation for simulating the effects of untried malpractice reforms on health care expenditures and outcomes, based on their predicted effects on the malpractice pressure facing medical providers.     

The integration movement in California's workers' compensation market

Over the past two decades the California workers' compensation industry has been responding to rapidly rising medical costs. The first response was to attempt to adopt principles of managed care; the second, to increase efficiency by integrating activities, first within companies, then between companies and providers, and finally across companies providing both group health and workers' compensation. This article chronicles the integration movement, analyzes the forces driving it, and discusses how contradictory government incentives have both propelled and hindered integration.     

Proposal to reimburse occupational medicine disease and injury claims through third party health insurance

The current system of compensation for the medical costs of occupational illnesses and injuries, a component of health insurance coverage for most workers in the United States, has recently come under scrutiny in the national health care reform debate. The cost of treatment of these conditions is significant, and there exist numerous disincentives for physicians and patients to use the workers' compensation system. Physicians who treat workers with occupationally related diseases may find compensation for a condition is disputed at the same time that it is excluded from payment by third party insurance coverage, leaving the patient selectively uninsured for at least some medical care services. In addition, most workers' compensation programs have been designed in a way that discourages efficient resource use by providers and claimants. We propose allowing health care providers to bill third party health insurers for all care, including work-related diseases and injuries. Insurers, in turn, would bill workers' compensation programs for associated treatment costs. The potential advantages of such a system include reductions in inefficiency and unfair burdens placed on providers and patients, in reporting bias, and in administrative costs balanced against the risks of insurers excluding workers in high risk occupations from obtaining low cost health insurance and shifting away from employers the administrative burden for workers' compensation.     

Expanding the role of nurse practitioners: effects on rural access to care for injured workers.

CONTEXT: A 3-year pilot program to expand the role of nurse practitioners (NPs) in the Washington State workers' compensation system was implemented in 2004 (SHB 1691), amid concern about disparities in access to health care for injured workers in rural areas. SHB 1691 authorized NPs to independently perform most functions of an attending physician. PURPOSE: The aims of this study were to (1) describe the contribution by NPs to Washington's workers' compensation provider workforce, (2) evaluate change in provider availability attributable to SHB 1691, and (3) evaluate the effect of SHB 1691 on timely accident report filing. METHODS: Administrative data were used to evaluate this natural experiment, using a pre-post design with primary care physicians (PCPs) as a nonequivalent comparison group. FINDINGS: NPs served injured workers with characteristics similar to those served by PCPs, but 22.0% of NPs were rural, compared with 17.3% of PCPs. Of claimants with NPs as their attending provider, 53.3% were injured in a rural county, compared with 24.7% for those with PCP attending providers. The number of NPs participating in the workers' compensation system rose after SHB 1691 implementation, more so in rural areas. SHB 1691 implementation was associated with a 16 percentage point improvement in timely accident report filing by NPs in both rural and urban areas. CONCLUSIONS: Authorizing NPs to function as attending providers for injured workers may improve provider availability (especially in rural areas) and timely accident report filing, which in turn may improve worker outcomes and system costs.     

Ten years' experience using an integrated workers' compensation management system to control workers' compensation costs

This work presents 10 years of experience using an Integrated Workers' Compensation Claims Management System that allows safety professionals, adjusters, and selected medical and nursing providers to collaborate in a process of preventing accidents and expeditiously assessing, treating, and returning individuals to productive work. The hallmarks of the program involve patient advocacy and customer service, steerage of injured employees to a small network of physicians, close follow-up, and the continuous dialogue between parties regarding claims management. The integrated claims management system was instituted in fiscal year 1992 servicing a population of approximately 21,000 individuals. The system was periodically refined and by the 2002 fiscal year, 39,000 individuals were managed under this paradigm. The frequency of lost-time and medical claims rate decreased 73% (from 22 per 1000 employees to 6) and 61% (from 155 per 1000 employees to 61), respectively, between fiscal year 1992 and fiscal year 2002. The number of temporary/total days paid per 100 insureds decreased from 163 in fiscal year 1992 to 37 in fiscal year 2002, or 77%. Total workers' compensation expenses including all medical, indemnity and administrative, decreased from $0.81 per $100 of payroll in fiscal year 1992 to $0.37 per $100 of payroll in fiscal year 2002, a 54% decrease. More specifically, medical costs per $100 of payroll decreased 44% (from $0.27 to $0.15), temporary/total, 61% (from $0.18 to $0.07), permanent/partial, 63% (from $0.19 to $0.07) and administrative costs, 48% ($0.16 to $0.09). These data suggests that workers' compensation costs can be reduced over a multi-year period by using a small network of clinically skilled health care providers who address an individual workers' psychological, as well as physical needs and where communication between all parties (e.g., medical care providers, supervisors, and injured employees) is constantly maintained. Furthermore, these results can be obtained in an environment in which the employer pays the full cost of medical care and the claimant has free choice of medical provider at all times.     

Legal Mechanisms Supporting Accountable Care Principles

Public health and private providers and facilities may shape the future of the US health system by engaging in new ways to deliver care to patients.“Accountable care” contracts allow private health care and public health providers and facilities to collaboratively serve defined populations. Accountable care frameworks emphasize health care quality and cost savings, among other goals.In this article, I explore the legal context for accountable care, including the mechanisms by which providers, facilities, and public health coordinate activities, avoid inefficiencies, and improve health outcomes. I highlight ongoing evaluations of the impact of accountable care on public health outcomes.As the US health system undergoes transformation, public health departments are engaging in new ways to deliver health care with private entities. One such method is “accountable care,” the coordinated provision of patient services by health care and public health providers and facilities with the goals of improving outcomes and avoiding inefficiencies.1 The core tenets of accountable care are prevention, health care quality, patient satisfaction for the population served, and cost savings to the health care system.1 Accountable care frameworks are based on risk and reward, with providers and facilities agreeing to collectively share the financial risk for a population in return for the opportunity to access rewards for attaining preestablished health care goals.Entities that seek to engage in accountable care are formed according to legal principles governing businesses and contracts, but federal and state laws2 specifically incentivize the formation and success of these entities by establishing antitrust waivers, fraud and abuse protections, and mandates to coordinate care. Although much has been written on the legal basis for establishing accountable care entities, with this article, I seek to inform public health practitioners of the relationship between the laws that recognize accountable care principles and the public health goals of improving patient care, impacting quality and outcomes, and measuring population health.In this article, I discuss 3 mechanisms by which providers, facilities, and public health may contract together to maintain legal entities that implement accountable care principles. First, health care providers and payers have pursued private contracts to provide accountable care to improve outcomes in their patient populations.3 Second, the Centers for Medicare and Medicaid Services authorizes Medicare reimbursements for legal entities certified as accountable care organizations (ACOs) through traditional fee-for-service and other payments upon meeting benchmark cost and quality standards.4 Third, state laws incorporate accountable care mechanisms into Medicaid provisions, permitting state programs to reimburse accountable care entities that serve vulnerable populations.5 Finally, I offer suggestions for evaluating the impacts of accountable care on public health outcomes.     

Economic Incentives in Disability Insurance and Behavioral Responses

This paper reviews evidence that economic incentives affect the behavior of workers and their health care providers. Prior models of disability behavior have been incomplete either because these incentive responses were ignored (as in the biomedical model of disability), or they focused exclusively on the workers' incentives (the insurance model) or the providers' incentives (the managed-care model). This paper calls for the use of the more expansive, integrated approach to disability management.     

The Washington state workers' compensation system: a case study

Washington State workers' compensation has researched applying managed care in workers' compensation through a series of research projects. In 1995 and 1996, the managed care project evaluated the impact of managed care on medical outcomes, patient satisfaction, and the cost control of medical care and disability. The managed care project also evaluated the long-term outcome of the cases by reviewing the participants 2 years after the injury. Finally,the managed care project evaluated the satisfaction of the employer with managed care. The Department of Labor and Industries Centers of Occupational Health and Education project currently is evaluating the impact of an occupational medicine-directed,education-oriented, protocol-guided pilot project.     

Predictors of ethical stress, moral action and job satisfaction in health care social workers

Value conflicts can be a source of ethical stress for social workers in health care settings. That stress, unless mediated by the availability of ethical resource services, can lead to social workers' dissatisfaction with their positions and careers, and possibly result in needed professionals leaving the field. This study explored social workers' experiences in dealing with ethical issues in health care settings. Findings showed the inter-relationship between selected individual and organizational factors and overall ethical stress, the ability to take moral actions, the impact of ethical stress on job satisfaction, and the intent to leave position.     

Occupational and environmental medicine in the United States: A proposal to abolish workers' compensation and reestablish the public health model

The workers' compensation model of occupational and environmental medicine should be converted to a public health model. Occupational and environmental medicine, as a part of the public health infrastructure,could play a much more substantive part in bringing about a national program to deal with occupational and environmental health. The workers' compensation insurance system could be discontinued at any time,but it will be vital to do so when national health insurance is adopted in the United States. Abolishing workers' compensation would remove the perverse incentives that currently undermine the practice of occupational medicine. Medical care for workers should be provided by health care professionals who are not subject to influence by employers or insurers.Eligibility for benefits should not be determined by health and safety professionals. Wage-replacement benefits for workers should be determined by guidelines established by government and industry that prevent manipulation of health and safety professionals by employers and insurers. A nationwide comprehensive system to track work-related injury and illness, superior to the current reliance on records provided by employers and collated by government agencies, should be adopted. When unusually high rates of injuries, illnesses,and fatalities occur, government inspectors ought to respond and regulate the industry accordingly.Occupational health and safety professional strained in public health can and should participate in these activities, but not when they are in the employ of industry or insurers.     

The Role of Health Care Providers in Long Term and Complicated Workers’ Compensation Claims

Introduction: Health care providers (HCPs) play a central role in workers’ compensation systems. In most systems, they are involved in the legitimization of work-related injury, are required to provide information to workers’ compensation boards about the nature and extent of the injury, give recommendations about return-to-work capability and provide treatment for injury or illness. This study identifies problems that occur at the interface between the health care system, injured workers, and workers’ compensation boards (WCBs) that may complicate and extend workers’ compensation claims and the mechanisms that underlie the development of these problems. Methods: Interviews were sought with injured workers, peer helpers and service providers from a variety of geographic locations in order to get a broad picture of return to work problems and concerns. This analysis includes data from total of 34 interviews with injured workers who had long term and complicated claims. Interviews were also conducted with 14 peer helpers and 21 service providers. Results: We identified four domains related to injured workers’ interface with the health care system that played a key role in complicating and prolonging compensation claims. These problems, related to health care access, conflicting or imperfect medical knowledge, limited understanding of compensation system requirements and confusion about decision-making authority, resulted in frustration, financial difficulties and mental health problems for injured workers. Conclusion: Recommendations are made about how compensation system parties can find better ways to serve injured worker health care needs and facilitate a smooth relationship between the compensation board and HCPs.     

Health, safety, and productivity in a manufacturing environment

The Health and Productivity Management model at International Truck and Engine Corporation includes the measurement, analysis, and management of the individual component programs affecting employee safety, health, and productivity. The key to the success of the program was the iterative approach used to identify the opportunities, develop interventions, and achieve targets through continuous measurement and management. In addition, the integration of multiple disciplines and the overall emphasis on employee productivity and its cost are key foci of the International Model. The program was instituted after economic and clinical services' analyses of data on International employees showed significant excess costs and a high potential for health care cost reductions based on several modifiable health risk factors. The company also faced significant challenges in the safety, workers' compensation, and disability areas. The program includes safety, workers' compensation, short-term disability, long-term disability, health care, and absenteeism. Monthly reports/analyses are sent to senior management, and annual goals are set with the board of directors. Economic impact has been documented in the categories after intervention. For example, a comprehensive corporate wellness effort has had a significant impact in terms of reducing both direct health care cost and improving productivity, measured as absenteeism. Workers' compensation and disability program interventions have had an impact on current costs, resulting in a significant reduction of financial liability. In the final phase of the program, all direct and indirect productivity costs will be quantified. The impact of the coordinated program on costs associated with employee health will be analyzed initially and compared with a "silo" approach.