Exam 3 - Provider Integrity

What is the focus of provider integrity?

Mitigating risks associated with poor behavior

What are behavioral risks?

Risks that compromise patient safety, lead to financial penalties, and erode trust in the healthcare system

How are behavioral risks addressed?

• Enhanced monitoring

• Data analytics

• Strict compliance

How can AI be used in provider integrity?

• Detect aberrant billing

• Strengthen credentialing

• Conduct audits

• Reduce unnecessary care incentives

7 types of healthcare risk?

• cybersecurity risk

• compliance risk

• reputational risk

• financial risk

• strategic risk

• operational risk

• clinical risk

What are key behavioral risks in healthcare?

• Fraud, waste & abuse

• Billing/upcoding or gamesmanship

• Telehealth exploitation

• Unnecessary utilization

• Pressure-induced behavior

• Unprofessional conduct

• Compliance gaps

• Clinical integrity issues

• Insider threats

What is medical fraud?

Intentional deception, misrepresentation, or fabrication of records to gain unauthorized payment

What is waste?

Unnecessary services

What is abuse?

Improper billing

What are examples of fraud, waste, and abuse?

• Billing for services not provided

• Upcoding

• Billing unnecessary services

• Accepting kickbacks

• Using someone else’s insurance

• Falsifying diagnoses

• Changing IDs to avoid Medicare/Medicaid rules

What are kickbacks?

Illegal exchange of money or gifts for patient referrals

What’s another term for billing “upcoding”?

gamesmanship

What is the purpose of upcoding?

To secure higher reimbursement through deceptive billing

What is upcoding?

Deceptively elevating charges to increase reimbursement

What duty does upcoding violate?

Fiduciary duty to manage assets responsibly

What is telehealth exploitation?

Fraudulent schemes involving improper or nonexistent patient visits

What risks are associated with telehealth exploitation?

• Data theft

• Fraudulent Medicare targeting

• False records

• Controlled substance distribution without oversight

What is unnecessary utilization?

Excessive or inappropriate services with little patient benefit to “cover all bases”

Examples of unnecessary utilization?

• Daily bloodwork/IV fluids

• Diagnostic testing

• Antibiotics for viral illness

• Routine imaging for low back pain

What percentage of ED visits are non-urgent and preventable?

Up to 60%

What percentage of healthcare spending is unnecessary?

10–30%

Where may unnecessary utilization occur?

behavioral health

What are examples of unnecessary healthcare spending?

• over diagnosis

• lack of care coordination

• defensive medicine

What is defensive medicine?

Providing extra care due to fear of litigation (being sued)

What is the purpose of pressure-induced behavior?

Use financial incentives and bonuses to pressure providers increase volume

What are the effects of pressure-induced behavior?

• Increased patient volume

• Ethical dilemmas

• Reduced specialist referrals

• Temporary compliance

What are examples of unprofessional conduct?

• Poor communication

• Lack of responsibility

• Ethical lapses

Consequences of unprofessional conduct?

• Medical errors

• Malpractice claims

• Reduced patient satisfaction

Examples of compliance gaps?

• Incomplete records

• Incomplete license verification

• Missing/improper consent

• HIPAA violations

• Outdated documentation

What do compliance gaps lead to?

Increased audits

What are clinical integrity issues?

Providing unnecessary or substandard care for financial gain

Examples of clinical integrity issues include?

• Conflicts of interest

• Falsifying data

• Ignoring patient input

• HIPAA violations

• Breach of ethical and professional standards

Consequences of clinical integrity issues?

• Compromised safety

• Loss of trust

• Poor care quality

What are insider threats?

Misuse of authorized access to sensitive health data

Types of insider threats?

• Malicious (intentional)

• Negligent (accidental by breaking protocol)

• Compromised (credentials stolen by external attackers)

Red flags of insider threats?

• After-hours logins

• Access outside job scope

• Unauthorized transfers

• Using unauthorized software

• Mass downloads

What motivates insider threats?

• Disgruntlement

• Financial gain

• External pressure

What are proactive compliance programs?

Frameworks to identify and manage fraud risks

Examples proactive compliance programs?

• Self-audits

• Monthly eligibility reviews

What is a culture of safety?

A blame-free environment encouraging reporting

How is technology used?

• Analyze billing patterns to ID risky practices early

• Share data between federal and state partners

What organizations set standards for leadership in addressing behavioral risks?

• The Joint Commission

• NCQA

Role of data analytics & AI?

Detect fraud patterns in real time

What is provider screening?

Background checks and exclusion lists from Medicaid/Medicare

What are compliance programs?

Training, audits, and reporting systems

What is monitoring & audits?

Reviewing claims and documentation

What is cultural & ethical training?

Promoting patient safety over profit

What do CMS (centers for medicare & medicaid services) and HHS-OIG (office of inspector general) do?

Detect and prosecute fraud

How much was recovered in FY 2024 from Medicaid fraud?

$1.4 billion

Penalties for fraud/unethical behavior?

• Repayment

• Fines

• Criminal prosecution

Why are regulatory and enforcement action necessary?

• protect safety

• ensure quality of care

• safeguard financial resources

What are consequences of integrity failures?

• exclusion from programs

• financial and legal penalties

• loss of licensure

• impact on patient outcomes

What happens to providers convicted of fraud?

Excluded from federal programs

What are financial and legal consequences of integrity failures?

Fines, penalties, and prison

What are loss of licensing consequences of integrity failures?

revocation via state board due to substandard service or criminal conviction

What are impact on patient outcomes in consequences of integrity failures?

Poor outcomes and safety risks

What is unprofessional behavior?

A wide range of misconduct affecting care

What are the main professional concerns?

• interpersonal misconduct

• clinical and professional misconduct

• inappropriate patient interactions

What is interpersonal misconduct?

Behavior disrupting team cohesion

Effects of interpersonal misconduct?

Increased medical errors

What are types of interpersonal misconduct?

• incivility and rudeness

• passive-aggressive behavior

• bullying and harassment

• verbal and physical aggression

What type of interpersonal misconduct is most frequently reported?

incivility and rudeness

Examples of incivility?

• Eye rolling

• Sarcastic

• Demeaning comments

• Public criticism

• Humiliation of Colleagues

Examples of passive-aggressive behavior?

• Intentional failing to respond to pages or calls

• Withhold info critical for patient care

• Excluding
  colleagues from decision-making

What is bullying & harassment?

• Persistent intimidation of staff or students

  • Usually within power hierarchy

  • Sexual Harassment

  • Discrimination based on Gender, Race or Disability

What is verbal/physical aggression?

Yelling, throwing objects, assault

What are types of clinical and professional misconduct?

• breaches of confidentiality

• practice outside scope

• incompetence and negligence

• patient abandonment

What are breaches of confidentiality?

• discussing sensitive PT info in public areas

• discussing with individuals not involved with care

What is practicing outside scope?

• performing procedures or treatments without
  license, qualifications or supervision

What is incompetence and neglicence?

Fail to follow safety protocols: infection control or
surgical time out requirements

What is patient abandonment?

Leave a patient without transfer of care OR fail to
report to incoming staff at end of shift

What are examples of inappropriate patient interactions?

• mocking & disrespect

• inappropriate boundaries

• lack of advocacy

What is mocking/disrespect?

Make jokes about patient condition, while under anesthesia or post disparaging content about them on social media

What are inappropriate boundaries?

Romantic/sexual relationships with patients or family members

What is lack of advocacy?

• ignoring patient concerns

• not providing informed consent

• not suggesting affordable treatment options to those in need

What are examples of interventions?

• corrective action plans (CAPs)

• address unprofessional/disruptive behavior

• early intervention

• supportive resources

What are corrective action plans (CAPs)?

Training and education to fix behavior

How to address unprofessional/disruptive behavior?

formal reporting and protocol

What is early intervention?

Detecting changes in mood, performance, and attendance

What supportive resources are used?

• Counseling

• Coaching

• Wellness programs