Quality of care factors will increasingly affect the claims submission and payment process for healthcare providers.
The impact of quality will range from coding requirements to the use of incentive payments to outright denials of payments for slipshod care. And hospitals will also face new requirements to collect quality data and provide it to government entities and payers.
The emphasis on quality will require providers to improve operations and prompt cooperation between the billing office and quality personnel, said panel participants at a revenue cycle conference sponsored by the
Healthcare Financial Management Association.
At the extreme perspective, payers could refuse to pay for the care and corrective action resulting from a serious medical error.
This past summer, the Centers for Medicare and Medicaid Services stated its intent to eliminate payments for "never events," such as when a patient suffers unintended injury, illness or death as a result of major medical errors. Some 27 "never events" were outlined by the National Quality Forum in 2002, including wrong-site surgeries, medication errors and serious decubitus ulcers.
“This is where healthcare is going; these are the things that we can avoid,” said Pat Merryweather, senior vice president with the Illinois Hospital Association.
Several states are requiring public reporting of adverse events. Illinois, for example, requires hospitals to develop plans for corrective actions. Merryweather says nurses also are looking at error rates as quality indicators affecting their decision of where to work.
In Florida, the state Legislature passed a law in 2004 to increase transparency in healthcare pricing. Quality measures also are a part of the FloridaComparecare.gov Web initiative, said Kim Streit, vice president of healthcare research and information for the Florida Hospital Association.
The law required the state’s Agency for Health Care Administration to create a consumer-friendly Web site with information on hospitals and ambulatory surgery centers, health plans, physicians and pharmaceutical prices.
The site went live in November 2005 and was updated this past July. Among the data on inpatient and ambulatory surgery sites are volume, charges and average lengths of stay for adults and children for 66 procedures and conditions, mortality rates, overall readmission rates and complications and infection rates, Streit said.
There’s been increased activity in the site by health plans. For example, Blue Cross Blue Shield of Florida has partnered with the Joint Commission on Accreditation of Healthcare Organizations to provide quality data to providers in the network.
In Illinois, the state has passed the Hospital Report Card Act and expects to expand reporting to cover things like conditions present on admission, do-not-resuscitate documentation, diagnosis and procedure codes and other data, Merryweather said.
The IHA and state are phasing in joint collection activities beginning in January, anticipating required reporting.
Illinois hospitals, especially those near Chicago, get to see the new quality wrinkles that CMS is considering, Merryweather said. The agency is expecting quality discussions to appear regularly on the agendas of boards of directors, not just limited to staff discussions. Hospitals risk citations now if a similar quality problem occurs in two departments, even if the incidents are isolated.
"Medicare is playing very hard on this issue,” she said. "This is not going to go away."