Attend any convention geared towards long-term and post-acute well being care operators, and also you’ll hear a standard thread: Knowledge is king.
In a panorama outlined by value-based fee fashions corresponding to Medicare Benefit plans and accountable care organizations (ACOs), investing in knowledge analytics has grow to be nearly a prerequisite for fulfillment.
If a given operator can show its energy on quite a lot of key metrics — decrease rehospitalization charges, diminished episodic prices — its buildings usually tend to win entrance into hospitals’ most popular supplier networks, and in addition probably appeal to curiosity from buyers.
However potential companions aren’t the one ones that knowledge.
Each the federal authorities and unbiased teams have entry to an growing fountain of statistics about nursing residence efficiency and compliance, making the rise of information a double-edged sword for suppliers fearful about attracting the eye of regulators — and probably going through pricey False Claims Act (FCA) instances.
“As claims knowledge and comparable info grow to be more and more accessible to analytics companies, suppliers ought to count on to see extra opportunistic FCA instances introduced based mostly on knowledge analytics and for conventional relators (corresponding to staff or former staff) to hunt to bolster their instances by publicly accessible reimbursement knowledge,” regulation agency Bass, Berry & Sims famous in its current recap of 2019 well being care fraud and abuse instances. “These instances function an essential reminder to suppliers to know their very own knowledge as a result of the federal government and relators actually are endeavoring to take action.”
The Nashville-based agency launched the report only a few weeks earlier than Facilities for Medicare & Medicaid Companies (CMS) administrator Seema Verma laid out an aggressive plan to interrupt down the partitions between operators and the federal authorities as a part of the company’s general enforcement efforts.
“Shifting to a system the place we’re capable of take high quality knowledge from the EHR, we are able to mix it with claims knowledge, we are able to see what’s occurring in program integrity,” Verma stated on a Tuesday name with reporters. “And we must always be capable to establish these high-quality suppliers on the entrance finish, after which establish the place now we have weaknesses — I believe, in a method, that’s been pretty unprecedented.”
CMS has already set data-based plans in movement on quite a lot of fronts, together with its initiative to streamline the enforcement of state-level survey businesses for nursing houses, significantly across the issuance of civil financial penalties (CMPs).
“In accordance with our personal knowledge, we noticed that CMPs have been being levied at a stage eight instances larger in some components of the nation than in others,” Verma stated in a Tuesday speech on the CMS High quality Convention in Baltimore. “Even accounting for geographic variations in high quality of care, this variation was one which known as for a proof.”
CMS will lengthen that effort to the accreditation businesses that approve Medicare-certified amenities, Verma stated this week, based mostly on discrepancies between precise outcomes and CMS analyses of their knowledge.
Verma’s full-throated assist of information initiatives is simply the most recent step in a brewing pattern on the company, which chief medical officer Kate Goodrich defined in much more specific phrases on a CMS podcast episode launched final summer season.
“We have now a treasure trove of information right here at CMS,” Goodrich stated. “We’re mining these knowledge to notice massive patterns and establish employees inside nursing houses with a earlier historical past of abuse.”
Goodrich’s phrases additionally observe with numerous warnings raised across the new Affected person-Pushed Cost Mannequin (PDPM) for Medicare nursing residence reimbursements — designed partly to cut back the potential for fraud by eradicating monetary incentives for offering as a lot remedy as attainable, and as an alternative basing funds on resident want.
However the system doesn’t remove the temptation for fraud totally; it merely shifts the definition of wrongdoing away from offering an excessive amount of remedy and towards the potential rationing of care with the intention to scale back bills.
That specter rose over the trade nearly instantly after PDPM’s implementation on October 1, when tales of remedy layoffs and hour cuts swept the area.
“I believe it’s actually short-sighted that these corporations are doing this, as a result of they know CMS is watching, and so they know if they’ve a dip in outcomes or dip in utilization, CMS might be going to audit them,” Kara Gainer, director of regulatory affairs for the American Bodily Remedy Affiliation, stated final fall.
Crucially, the shift to a brand new fee mannequin doesn’t take away the federal authorities’s potential to go after suppliers for alleged fraud dedicated below the previous system. Simply final week, operator Diversicare Healthcare Companies (OTC: DVCR) introduced the profitable completion of an eight-year FCA investigation into its remedy practices in a deal that included a $9.5 million settlement.
The identical day, the Division of Justice touted a $15.5 million FCA settlement with Guardian Elder Care, resolving allegations of offering pointless remedy companies that stretched again to 2011.
“Billing federal well being care applications for medically pointless rehabilitation companies not solely depletes these applications’ funds but in addition exploits our most weak residents,” U.S. lawyer Scott Brady stated in an announcement asserting the deal. “Our workplace will proceed to aggressively pursue suppliers who reap the benefits of our seniors by placing monetary achieve forward of affected person care.”
Within the Guardian case, a pair of former staff tipped off the DOJ and acquired a good portion of the settlement — $2.eight million — below the qui tam provisions of the False Claims Act. Whistleblowers generally issue into these investigations and eventual resolutions, however Bass, Berry & Sims warned that the information revolution might make such on-the-ground observations irrelevant.
“A variety of current qui tam lawsuits have been filed by company data-analytic relators looking for to pursue FCA allegations in opposition to well being care suppliers by mining Medicare claims knowledge or different publicly accessible knowledge sources,” the Nashville, Tenn.-based agency famous. “Lawsuits pursued by such relators are usually not characterised by private data of factual info related to the alleged wrongdoing, which is the everyday hallmark of well-pleaded FCA allegations. Slightly, these skilled relators are opportunistic, drawing inferences of fraud based mostly on their very own knowledge evaluation.”
Bass, Berry & Sims specifically recognized a Texas-based agency that solely brings fraud instances based mostly on analytics, together with accusations of improper remedy provision at expert nursing amenities. Whereas that particular group has not but satisfied the federal authorities to pursue a case, the agency warned that danger stays for operators within the trade.
“Suppliers have had solely blended leads to looking for dismissal of those instances on the pleading stage below the FCA’s public disclosure bar and Rule 9(b),” the agency noticed, referring to the burden of proof that accusers should clear.