Choose your program: QA versus compliance

October 15, 2007

The need for quality assurance and compliance programs has grown in recent years because of legislation, such as the Health Insurance Portability and Accountability Act. Both QA and compliance programs can be good for a patient's bottom line.

Keypoints:

Quality assurance (QA) and compliance programs are closely related. Ophthalmology practices that have instituted one type of program are well on the way to having the other, according to two specialists in the fields.

In their presentation "Quality assurance versus compliance programs," Donna M. McCune, vice president of San Bernardino, CA-based Corcoran Consulting Group, and Allison W. Shuren, partner in the Washington, DC, law firm Arent Fox LLP, discussed the similarities between-and importance of-QA and compliance programs.

The need for both types of programs has grown in recent years with the advent of legislation, such as the Health Insurance Portability and Accountability Act, and increasingly stringent rules for reimbursement set by the Office of the Inspector General and by Medicare.

"The bottom line is you need to do something," said McCune. "You can't just sit on your hands these days, because it's increasingly likely that sometime in your career someone will look at how you conduct your practice."

Quoting Taber's Cyclopedic Medical Dictionary, McCune defined QA as "activities and programs designed to achieve the desired levels of care." Although most people associate the term with the quality of the medical care itself, she said, the same principles used to ensure quality in medical care also can be applied to administrative issues such as billing and coding. One of the best ways to establish goals for a practice's QA program, according to McCune, is to align them with the goals of Medicare's Pay It Right program.

"They want to pay the right amount to the right provider for the right service to the right beneficiary," she explained. "So in your practice you need to ask questions like, 'Did we receive the correct amount? Did we submit the claim to the proper provider? Did we bill under the appropriate beneficiary name?" Most QA programs operate fairly informally.

"There is no recipe. You make it what you want it to be," McCune said. The advantage of an informal approach is that once a template or guidelines are established for one part of a practice, they are easily transferable to another part. For example, one practice with which McCune's firm worked wanted to focus on reimbursement. Checklists were developed with activities to be performed at each step along the way, beginning with the appointment clerk.

"She reviewed each patient's information-insurance, the patient's address, and made sure the patient had a signature on file," McCune said.

After that, the practice developed similar lists for technicians, physicians, transcribers, the billing office, and even human resources. They reviewed progress after 6 months and found that far fewer claims were being rejected or returned.

"They weren't perfect, but they certainly had improved," she said.

One of the important prerequisites of an effective QA process, she added, is making sure employees have sufficient resources to carry it out. That includes access to the Internet, where growing numbers of carriers are posting information necessary for filing claims. "If you're going to hold your people accountable, give them access to the resources they need," McCune said.

QA and compliance programs also can be good for the bottom line, according to Shuren, because many more commercial carriers are instituting pay-for-performance programs. "As service providers, you're going to need some way of making sure you meet the benchmarks carriers are developing so you get the extra payment," she said.

By the book

Shuren said that, unlike QA programs-which are meant primarily to improve the level of care and administrative procedures in a practice-compliance programs focus on reducing waste, fraud, and abuse. She defined such programs as "a series of internal controls that have been articulated to promote the prevention, detection, and resolution of conduct or practices that are illegal or do not conform to the practice's ethical standards."