Board’s Responsibility
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Board’s Responsibility Board’s Responsibility Most healthcare professions overseen Most healthcare professions overseen by a variety of organizations by a variety of organizations Chiropractic (due to the Chiropractic (due to the independence and lack of full independence and lack of full integration) does not have as much integration) does not have as much oversight oversight Boards have a fiduciary Boards have a fiduciary responsibility to assure health, responsibility to assure health, safety, welfare & safety, welfare & quality of care quality of care
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Board’s Responsibility. Most healthcare professions overseen by a variety of organizations Chiropractic (due to the independence and lack of full integration) does not have as much oversight Boards have a fiduciary responsibility to assure health, safety, welfare & quality of care. - PowerPoint PPT Presentation
Transcript of Board’s Responsibility
Board’s ResponsibilityBoard’s Responsibility
Most healthcare professions overseen by Most healthcare professions overseen by a variety of organizationsa variety of organizationsChiropractic (due to the independence and Chiropractic (due to the independence and lack of full integration) does not have as lack of full integration) does not have as much oversightmuch oversightBoards have a fiduciary responsibility to Boards have a fiduciary responsibility to assure health, safety, welfare & assure health, safety, welfare & quality of quality of care care
The Need for BPThe Need for BP
85% of 85% of allall healthcare is estimated to be healthcare is estimated to be scientifically invalidscientifically invalidIf Dr. read one paper/day for 1yr-99 years If Dr. read one paper/day for 1yr-99 years behindbehindThere is increasing demand for evidence There is increasing demand for evidence in practicein practiceAdvent of pay for performance-MedicareAdvent of pay for performance-Medicare
Current increased public Current increased public awareness of fraud & abuseawareness of fraud & abuse
PI overutilization- Payor complaints to PI overutilization- Payor complaints to BORBORLocal DA prosecution of Docs for criminal Local DA prosecution of Docs for criminal chargeschargesAttorney firms specializing in ins. Fraud to Attorney firms specializing in ins. Fraud to gain big insurance contractsgain big insurance contractsMedicare Fraud-coding, billing, document.Medicare Fraud-coding, billing, document.
Current increased public Current increased public awareness of fraud & abuseawareness of fraud & abuse
FBI Investigations into multidisciplinary FBI Investigations into multidisciplinary practicespracticesPatient complaints to BORPatient complaints to BOR
FraudFraud
Require deceptionRequire deceptionIntentional misrepresentationIntentional misrepresentationFinancial gainFinancial gain
IME/ICE board examplesIME/ICE board examples
“ “ you have indicated that your IME you have indicated that your IME evaluation was based on your opinions, …evaluation was based on your opinions, …and this is based on your knowledge, and this is based on your knowledge, educational training and educational training and experience”……… which may fail to experience”……… which may fail to uphold the validity and reliability of your uphold the validity and reliability of your evaluation in a legal forum”evaluation in a legal forum”
Best Practices & RegulationBest Practices & Regulation
How does the Best Practices How does the Best Practices effect our Boards?effect our Boards?
How may the BP be applied by How may the BP be applied by the Boards?the Boards?
ImplementationImplementation
Training and certification course is being Training and certification course is being developeddevelopedDoc available at Doc available at www.ccgpp.orgwww.ccgpp.orgComments requested from all Comments requested from all stakeholdersstakeholdersBoard consensus comments to Board consensus comments to [email protected]@comcast.net or or [email protected]@fclb.org
How does this apply to the How does this apply to the Licensing Boards.Licensing Boards.
BOR has to determine:BOR has to determine:1.1. Appropriateness of careAppropriateness of care2.2. Abuse of careAbuse of care3.3. Overutilization of care Overutilization of care 4.4. FraudFraud
AbuseAbuse
Incidents or practices of providers that are Incidents or practices of providers that are inconsistent with accepted sound clinical, inconsistent with accepted sound clinical, business or fiscal practicesbusiness or fiscal practicesExcessive or unnecessary careExcessive or unnecessary careImproper or sloppy business practicesImproper or sloppy business practicesPoor clinical documentationPoor clinical documentationImproper coding or billing mistakesImproper coding or billing mistakesUnintentionally mispresentation of factsUnintentionally mispresentation of facts
FraudFraudOverutilization is fraud if it is proved to be Overutilization is fraud if it is proved to be intentionalintentionalHow can you prove intent?How can you prove intent?– Individual case proofIndividual case proof– Clinical evidence with support from external evidence Clinical evidence with support from external evidence
based literaturebased literature– Consistency across a number of casesConsistency across a number of casesDocumentation & appropriate clinical decision Documentation & appropriate clinical decision making based on the evidencemaking based on the evidenceBP will provide the reliable source for the BP will provide the reliable source for the evaluationevaluation..
How can BP help?How can BP help?
Boards need some type of basis to Boards need some type of basis to demonstrate demonstrate what is appropriatewhat is appropriate care to care to substantiate the decisions on case reviewssubstantiate the decisions on case reviewsMust have a “preponderance of evidence”Must have a “preponderance of evidence”
& it must be “clear and convincing”& it must be “clear and convincing”BP is the answer as a resource!BP is the answer as a resource!
How can BP help?How can BP help?
IME/ICE and Record Review Dr IME/ICE and Record Review Dr complaintscomplaints– Improper opinionated denial of careImproper opinionated denial of care– Improper parameters of dosage and Improper parameters of dosage and
frequency set up by opinionfrequency set up by opinion– Improper denial of modalities or other Improper denial of modalities or other
treatments- based on “cherry picking” treatments- based on “cherry picking” literatureliterature
IME/ICE board examplesIME/ICE board examples
There is a lack “ of description of the There is a lack “ of description of the missing supportive clinical evidence”missing supportive clinical evidence”““the report did not contain any references the report did not contain any references to any recognized source…which you may to any recognized source…which you may have utilized in reaching your conclusion”have utilized in reaching your conclusion”““your assertion that only 3 txs were your assertion that only 3 txs were necessary…based on age…takes away necessary…based on age…takes away from the actual objective clinical elements from the actual objective clinical elements of the patient presentation”of the patient presentation”
IME/ICE board examplesIME/ICE board examples
““there is an obligation for an adequate there is an obligation for an adequate factual basis for any and all professional factual basis for any and all professional opinions expressed”opinions expressed”““to ensure opinions are based on accepted to ensure opinions are based on accepted data… it must be from currently accepted data… it must be from currently accepted clinical literature”clinical literature”““the report did not indicate what clinical the report did not indicate what clinical findings or facts led you to your findings or facts led you to your conclusions”conclusions”
IME/ICE board examplesIME/ICE board examples
“ “ it is the board’s stance that an objective it is the board’s stance that an objective IME review shall be based on a IME review shall be based on a comparative assessment of case comparative assessment of case findings…with the published research and findings…with the published research and common practice ”common practice ”
Evidence BasedEvidence Based
Adjudicatory reviews and subsequent Adjudicatory reviews and subsequent hearings will progress with a defined hearings will progress with a defined substance that licentiates will have to substance that licentiates will have to addressaddressDiminished judgment calls-aids both Diminished judgment calls-aids both plaintiff and defendantplaintiff and defendantAppeals will be upheld due to consistency Appeals will be upheld due to consistency of evidence that decisions are basedof evidence that decisions are based
Practical UsagePractical Usage
Aids providers in substantiating med. Nec.Aids providers in substantiating med. Nec.Allows negotiations on artificial stop care Allows negotiations on artificial stop care limitslimitsAids in enhancing quality of care by Aids in enhancing quality of care by utilization of benchmarking as a baseline.utilization of benchmarking as a baseline.
Practical UsagePractical Usage
Addresses underutilizationAddresses underutilizationPromotes more equitable and fair payor Promotes more equitable and fair payor judgmentsjudgmentsDoes not follow algorithms, includes pt Does not follow algorithms, includes pt individuality, and clinical experience and individuality, and clinical experience and judgment of Dr.judgment of Dr.Aids in clinical decision making on pt pop.Aids in clinical decision making on pt pop.Allows focus on process of care and Allows focus on process of care and dose/responsedose/response
Benchmark-Low BackBenchmark-Low Back
90%-90 days- symptom improvement90%-90 days- symptom improvement40%-6 months40%-6 months62%- 1year62%- 1year
Common Complicating/Risk Common Complicating/Risk Factors –Physical or personalFactors –Physical or personal
– AgeAge– GenderGender– Severity of SymptomsSeverity of Symptoms– Prior SurgeryPrior Surgery– Prior recent injury (<6mo)Prior recent injury (<6mo)– Poor Body MechanicsPoor Body Mechanics– Falling as mechanism of injuryFalling as mechanism of injury
Risk Factors-BiomechanicalRisk Factors-Biomechanical
– BiomechanicalBiomechanicalProlonged static postureProlonged static posture
Poor Spinal motor controlPoor Spinal motor control
Sustained trunk loadSustained trunk load
Frequent bending, twisting, lifting, pushing, pullingFrequent bending, twisting, lifting, pushing, pulling
Risk Factors-PsychosocialRisk Factors-PsychosocialChronicityChronicity
Attorney RetentionAttorney Retention
Employment SatisfactionEmployment Satisfaction
Expectations for recoveryExpectations for recovery
Participation in social welfare or disability programParticipation in social welfare or disability program
Risk Factors-physiolog. Red/yellow Risk Factors-physiolog. Red/yellow flags.flags.
DJD, articular inflammatory dz, boney dzDJD, articular inflammatory dz, boney dz
Spinal stenosis, or physiol. narrow canalSpinal stenosis, or physiol. narrow canal
Osteoporosis, bone weakening disordersOsteoporosis, bone weakening disorders
ScoliosisScoliosis
Neurological signs or symptomsNeurological signs or symptoms
Write this down!Write this down!
Best Practices is not a standard!Best Practices is not a standard!Best Practice is a resource that bridges Best Practice is a resource that bridges the gap between the researchers and the the gap between the researchers and the clinicians or between laboratory and clinicians or between laboratory and practicepracticeBest Practices takes into account the Best Practices takes into account the clinicians experience and judgment along clinicians experience and judgment along with the individual patients unique with the individual patients unique personal values, presentation and desires personal values, presentation and desires
ImplementationImplementation
Implementation Recommendation: Implementation Recommendation:
Internal board policy or ruleInternal board policy or rule
Not statute, or regulation.Not statute, or regulation.
ImplementationImplementation
Training and certification course is being Training and certification course is being developeddevelopedDoc available at Doc available at www.ccgpp.orgwww.ccgpp.orgComments requested from all Comments requested from all stakeholdersstakeholdersBoard consensus comments to Board consensus comments to [email protected]@comcast.net or or [email protected]@fclb.org
