Ethics Toolbox: Integrity, Disparity, and Payment
March / April 2006
Ethics Toolbox
Integrity, Disparity, and Payment
Integrity refers to a state of being or level of action where there is soundness — where correctness and consistency are maintained in behavior as well as data. Characterized both as the internal accuracy and consistency of a process, integrity serves as the disposition and foundation that drives our choices and actions. Integrity, a fundamental underpinning of personal character, is a powerful tool that can help us navigate the thicket of ambiguity and guide us away from potential liability and trouble.
We associate the term “integrity” with concepts such as wholeness, honesty, and sincerity. It may be argued that integrity is the substructure of a personal ethic. Since the nature of integrity has a wide range of expressions, the ways we integrate integrity into our personal lives and professional practices are diverse, while traversing a broad continuum. Integrity drives some people to toe the line and act in a risk aversive manner, keeping within acceptable guidelines and measures. Others relish teetering on the fine line, attempting to balance between propriety and impropriety. Skirting the fine line invites scrutiny and sometimes trouble.
There is no area that invites more scrutiny by the powers that be — such as the Office of Inspector General (OIG) of Health and Human Services — than the integrity of payment systems. The OIG is most attentive to ferreting out fraud and identifying significant payment disparity issues. They even call their charge in this domain “integrity management.” They are concerned with the integrity of proper payment and reducing and preventing abuse, including billing and payment error. Obviously, payment errors can range from clerical mistakes and unintentional inaccuracies to intentional and deliberate billing fraud.
Addressing errors in reimbursement within the broad and complex matrix of healthcare-related services raises questions and concerns when it comes to implementing a consistent strategy for resolving identified payment error. There is obvious and dramatic disparity between the approach taken by the American Medical Association (AMA) and the approach recommended by the Institute of Medicine (IOM).
The AMA favors establishing a blame-free environment that cultivates openness and offers impunity. Others recommend that we cultivate a culture of talking openly about patient safety, and channeling attention towards error-prone systems, not individuals. In contrast, the IOM advocates a guns-and-badges approach that provides the OIG the ability to levy stringent fines, accompanied by free room and board at “Club Fed.” Cultivating a culture that discloses information about billing and payment errors, with the objective of allowing practitioners to fix the process, has now been juxtaposed with the prospect of punishment. The concept of being held accountable for violations may have an extremely chilling effect on physicians’ willingness to discuss and acknowledge such errors. The unintentional disparity between openness and heavy handedness has had a significant negative impact on the learning that may come from being open about mistakes, misadventures, and errors.
Closer scrutiny shows that this apparent disparity is not as extreme as it first appears. These views are not mutually exclusive. We want to improve payment integrity, but cannot ignore the culpability of intentional abuse. Accordingly, we must hold those who commit intentional abuse accountable. We cannot ignore unacceptable, abusive practices such as intentional over-billing or billing for services not rendered,Ýnor condone misleading the patient by performing non-indicated surgeries or unnecessary diagnostic procedures at the patient’s expense and peril. We must be able to accurately identify and accommodate reasonable errors and inaccuracies without creating a culture of fear, heavy handedness, and avoidance.
Integrity must serve as the primary driver of our care delivery and business-related operations. Quality oversight can help to identify errors, understand the root causes, and take corrective and preventive action to resolve these errors. These systematic processes are designed to restore and help maintain healthcare integrity. Such systems promote compliance and simultaneously raise the bar, yet compliance is not “ethics.” One may comply to avoid sanctions, rather than being driven by the desire to do the “right” thing. Compliance must be more than making the OIG happy. One’s efforts should be fueled by “doing the right thing because it’s the right thing to do,” rather than by the fear of sanction or reprisal. At the expense of redundancy, the right thing should be done because it is our “intent” to do the right thing. It requires our “intent” to provide needed healthcare services and to accurately bill for the services rendered. If it is our “intent” to fulfill our duties and to be open and honest, we ensure that our actions will accurately reflect our integrity.
Physicians must weave the “intent” of integrity from their daily lives into the fabric of their billing practices. Integrity within our healthcare system is achievable, provided we “intentionally” design it to be that way. We cannot separate ourselves from the systems we design. The design of our healthcare system reflects just who we are, how we live our lives, how we value those for whom we care, and the level of integrity we value. Changing unwanted and unacceptable healthcare billing practices and inaccuracies requires that we design our healthcare system deliberately with “intentional integrity.”
Dennis Robbins (DennisRobbins@cox.net) is a nationally prominent healthcare innovator, author, and thought leader. He is president of Integrated Decisions, Ethics, Alternatives, and Solutions (IDEAS). He has served as an advisor on ethics and related issues for major national organizations, associations, law firms, hospital systems, private industry, and government. Robbins holds a PhD in philosophy from Boston College and a postdoctoral master’s degree in public health from Harvard. He is a member of the Editorial Advisory Board for Patient Safety and Quality Healthcare and member of several technical and scientific advisory boards. Robbins has more than three decades of academic and consulting experience. He is also an Adjunct Professor at the W.P. Carey School of Business at Arizona State University, where he teaches graduate courses in ethics and health law.
Mark Pilley (m.pilley@integriGuard.org) is a senior medical director for IntegriGuard, a wholly owned subsidiary of Lumetra, the QIO for California. IntegriGuard is a Program Safeguard Contractor (PSC), committed to establishing the benchmark for payment integrity systems review by investigating, auditing and conducting medical review to effectively reduce fraud, waste, and abuse. Pilley is Board Certified in Family Medicine, as well as a Fellow and board member for the American Academy of Disability Evaluating Physicians (AADEP). Prior to joining IntegriGuard, Pilley served as VP and Medicare Contract Medical Director (CMD) for Mutual of Omaha’s Part A Medicare Division. He has extensive experience and competency in analytics, synergistic investigation, quality assurance and utilization review, disability determinations and medical review, and currently serves as the Region D-DME-PSC Medicare Medical Director.
Joel V. Brill (Joel.Brill@verizon.net) is Chief Medical Officer of Predictive Health, LLC. Brill is nationally recognized for his expertise in coding and reimbursement methodologies coupled with service on national technology assessment and pharmacy and therapeutics committees. In 2005, Brill served as the co-chair of the Part D medication measures Technical Expert Panel for CMS. He is the American Gastroenterological Association advisor on practice management and reimbursement issues, and representative to the American Medical Association (AMA) RBRVS Update Committee (RUC), the CPT Editorial Panel, the Practice Expense Review Committee (PERC), and the AMA Physician Consortium for Performance Improvement.
Reference
American Medical Association. Policy H-335.956, Patient Safety. Available at www.ama-assn.org/apps/pf_new/pf_online?f_
n=browse&doc=policyfiles/HnE/H-335.965.HTM