Using proactive external peer review to mitigate the risk of high-dollar lawsuits
Medical necessity investigations and lawsuits are a significant threat to healthcare providers, especially those that rely on internal medical staff peer review programs to identify adverse patterns in clinical behavior, according to the new brief Medical Necessity: Checks and Balances Most Hospitals Don't Have, but Should.
"All too often, the medical staff is not up to the task of policing for medical necessity and therefore does not produce adequate oversight," says Rick Sheff, MD, chief medical officer and national director of external peer review at The Greeley Company. As a result, healthcare executives may not know the extent to which their organizations are at risk for fraudulent billing.
This is a critical issue, given the OIG has recently settled numerous multimillion-dollar lawsuits with hospitals and physicians for performing medically unnecessary tests and procedures.
Whistleblower lawsuits in particular are damaging to a hospital’s reputation and bottom line. "There is no shortage of people willing to blow the whistle in medical necessity cases and retire comfortably for their trouble," says Thomas Anthony, an attorney with Frost Brown Todd LLC. Whistleblowers receive between 15% and 30% of the amount recovered by the government.
Hospitals face big risks when the medical staff peer review process does not lead to medical necessity decisions that match OIG guidelines.
The brief describes how to establish an effective medical necessity surveillance and accountability program. One key step includes creating an external peer review process, which is a best practice for hospitals looking to reduce risks related to medical necessity. Experienced external peer reviewers not only perform impartial assessments, but also raise the red flag when self-reporting might be warranted. Go here to learn how to structure and implement medical necessity checks and balances.
The Greeley Company is a full-service healthcare consulting practice with specialties including Compliance & Quality, Bylaws & Governance, Medical Staff Optimization & Physician Alignment, External Peer Review, Credentialing & Privileging, Interim Staffing, and Education & Seminars. 888-749-3054 | www.greeley.com