보건의료(의료보험)기만행위와 프로그램 진실성에 대한 교육 확장시키기

보건의료(의료보험)기만행위와 프로그램 진실성에 대한 교육 확장시키기

Expanding Physician Education in Health Care Fraud and Program Integrity

Shantanu Agrawal, MD, MPhil, Bruce Tarzy, MD, Lauren Hunt, MPH, Julie Taitsman, MD, JD, and Peter Budetti, MD, JD

건강보험 프로그램에 대해 지속적으로 사기(fraud)행위를 하는 의사는 매우 적지만, 그 외에 것들(남용abuse, 실수error, 과용waste)에 대해서는 거의 대부분의 의사들이 기여하고 있다. 이러한 현상에 의한 영향력을 고려하면 프로그램 진실성(Program Integrity)에 대한 의사들의 의식 수준을 높이는 것이 무척 중요하다. 

Program integrity (PI) spans the entire spectrum of improper payments from fraud to abuse, errors, and waste in the health care system. Few physicians will perpetrate fraud or abuse during their careers, but nearly all will contribute to the remaining spectrum of improper payments, making preventive education in this area vital. 

Despite the enormous impact that PI issues have on government-sponsored and private insurance programs, physicians receive little formal education in this area. Physicians’ lack of awareness of PI issues not only makes them more likely to submit inappropriate claims, generate orders that other providers and suppliers will use to submit inappropriate claims, and document improperly in the medical record but also more likely to become victims of fraud schemes themselves.

저자들은 현재 여기에 대한 교육이 어떻게 되고 있는지를 포함한 전반적인 PI 이슈들을 살펴보고, PI 교육을 위한 교과과정을 제안하였다.

In this article, the authors provide an overview of the current state of PI issues in general, and fraud in particular, as well as a description of the state of formal education for practicing physicians, residents, and fellows. Building on the lessons from pilot programs conducted by the Centers for Medicare and Medicaid Services and partner organizations, the authors then propose a model PI education curriculum to be implemented nationwide for physicians at all levels. 

They recommend that various stakeholder organizations take part in the development and implementation process to ensure that all perspectives are included. Educating physicians is an essential step in establishing a broader culture of compliance and improved integrity in the health care system, extending beyond Medicare and Medicaid.

Module 1: Overview of health care fraud and broader PI issues

This module introduces physicians to the spectrum of PI issues, including waste, abuse, and fraud, with vivid case examples and a discussion of known fraud schemes. 

The module also includes a discussion of the legal and regulatory considerations for PI issues, including the civil and criminal penalties for fraud. 

Finally, the module describes the response of health care and law enforcement organizations to these issues to contextualize the daily activities of physicians within the broader PI framework.

Competencies and learning objectives:

• Learn the spectrum of PI issues, including the scope and variety of fraud and common fraud schemes and systemic issues such as conflicts of interest and perverse incentives.

• Learn the legal framework for PI issues.

• Learn how public regulatory agencies, law enforcement, and organized medicine are responding to PI issues.

Module 2: Preventive strategies to improve PI

This module provides physicians with a host of preventive approaches and tools to protect their medical identities, to institute practice safeguards and compliance activities, and to improve their communication with patients about PI issues. 

This module includes a discussion of a range of practice settings, including the use of midlevel providers, the corporate practice of medicine, practices in academic centers, and the use of alternative payment models.

Competencies and learning objectives:

• Learn the risk factors for and strategies to avoid medical identity theft.

• Learn the key elements of compliance programs to avoid fraudulent or abusive billing.

• Learn how to help patients avoid and identify fraud schemes.

• Learn how to access resources for further education or reporting of PI issues.

Module 3: Documentation and billing best practices

This module specifically addresses documentation and billing issues, with an emphasis on developing best practices and error prevention strategies, as well as understanding the consequences of shortcomings in these areas. 

The module also addresses the various types of payment and financial audits of physician practices, discussing the differences between them and how they differ from fraud investigations. As in Module 2, special attention is paid to the range of practice settings and major innovations and trends in health care.

Competencies and learning objectives:

• Learn the importance of accurate documentation and billing, including typical issues, relevant fraud schemes, and error prevention strategies.

• Learn about the various payer audits of physician practices and fraud investigations, including potential consequences.

• Learn documentation and billing best practices.

---

Acad Med. 2013 Aug;88(8):1081-1087.

Expanding Physician Education in Health Care Fraud and Program Integrity.

Agrawal S, Tarzy B, Hunt L, Taitsman J, Budetti P.

Source

Dr. Agrawal is medical director and director of data sharing and partnership, Center for Program Integrity, Centers for Medicare & Medicaid Services, Baltimore, Maryland. Dr. Tarzy is lead medical consultant, Medical Review Branch, California Department of Health Care Services, Sacramento, California. Ms. Hunt is health insurance specialist, Center forProgram Integrity, Centers for Medicare & Medicaid Services, Baltimore, Maryland. Dr. Taitsman is chief medical officer, Office of the Inspector General, Department of Health and Human Services, Washington, DC. Dr. Budetti is deputy administrator for program integrity and director, Center for Program Integrity, Centers for Medicare & Medicaid Services, Washington, DC.

Abstract

Program integrity (PI) spans the entire spectrum of improper payments from fraud to abuse, errors, and waste in thehealth care system. Few physicians will perpetrate fraud or abuse during their careers, but nearly all will contribute to the remaining spectrum of improper payments, making preventive education in this area vital. Despite the enormous impact that PI issues have on government-sponsored and private insurance programs, physicians receive little formal education in this area. Physicians' lack of awareness of PI issues not only makes them more likely to submit inappropriate claims, generate orders that other providers and suppliers will use to submit inappropriate claims, and document improperly in the medical record but also more likely to become victims of fraud schemes themselves.In this article, the authors provide an overview of the current state of PI issues in general, and fraud in particular, as well as a description of the state of formal education for practicing physicians, residents, and fellows. Building on the lessons from pilot programs conducted by the Centers for Medicare and Medicaid Services and partner organizations, the authors then propose a model PI education curriculum to be implemented nationwide for physicians at all levels. They recommend that various stakeholder organizations take part in the development and implementationprocess to ensure that all perspectives are included. Educating physicians is an essential step in establishing a broader culture of compliance and improved integrity in the health care system, extending beyond Medicare and Medicaid.