What can Certified Internal Auditors do that Will Prevent Healthplans from “Gaming” Providers, Purchasers, and the Public?
A Discussion Paper
Healthplans can employ various tactics to game Providers, purchasers and the public when offering value-based contracts and policies. These tactics can create challenges for providers, potentially undermining the goals of value-based care. Here are some ways Healthplans can game providers:
Gaming Tactics Used by Healthplans
1. Ambiguous Contract Terms:
Description: Health plans may draft contracts with vague or ambiguous terms regarding performance metrics, reimbursement models, and penalties.
Impact: Providers may find it difficult to understand and comply with the requirements, leading to unintentional breaches and financial penalties.
Example: Ambiguous definitions of "quality metrics" or "outcomes" that can be interpreted in multiple ways, leaving room for the health plan to penalize providers arbitrarily.
2. Unrealistic Performance Metrics:
Description: Setting performance metrics that are difficult or impossible to achieve.
Impact: Providers may struggle to meet these metrics, resulting in reduced reimbursements or penalties.
Example: Setting excessively high benchmarks for patient outcomes or readmission rates that are not achievable given the patient population.
3. Delayed Payments and Reimbursements:
Description: Delaying payments to providers for services rendered under value-based contracts.
Impact: Creates cash flow problems for providers, especially smaller practices that may depend on timely reimbursements to cover operational costs.
Example: Withholding payments until all performance data is validated, which can take several months.
4. Frequent Contract Changes:
Description: Regularly changing contract terms, performance metrics, or reimbursement structures.
Impact: Creates uncertainty and administrative burdens for providers who must constantly adapt to new requirements.
Example: Changing the weight of certain performance metrics mid-contract period, affecting the providers' ability to plan and achieve goals.
5. Complex and Opaque Data Requirements:
Description: Requiring providers to submit extensive and complex data without providing adequate support or clear guidelines.
Impact: Increases administrative burdens and costs for providers, making it difficult to comply and accurately report performance.
Example: Requiring detailed patient record and data submissions with frequent updates but not providing user-friendly systems, training or administrative compensation.
6. Selective Enforcement of Contract Terms:
Description: Enforcing contract terms selectively, penalizing some providers while being lenient with others.
Impact: Creates an uneven playing field and can demoralize providers who feel unfairly targeted.
Example: Penalizing smaller practices for minor breaches while overlooking more significant issues in larger, more influential practices.
7. Hidden Reimbursement Changes and Penalties:
Description: Including hidden fees and penalties in the contract that are not clearly communicated upfront.
Impact: Providers may incur unexpected costs that erode their financial viability.
Example: Imposing fees for data submission errors or minor compliance issues that were not clearly outlined in the initial contract.
8. Hidden Risk:
Description: Failure to follow generally accepted practice for risk-sharing and risk-adjustments.
Impact: Provider may be paid on the basis of a population of patients who require more services than providers were aware.
Example: Healthplan contracts with a purchasers who have members with a low case-mix severity. Purchaser then adds members who have a greater case-mix severity. Unless the risk is adjusted, the providers financial margin is diminished.
Can an Independent Certified Internal Auditor Address the Problem of Healthplans Gaming Providers, Purchasers, and the Public?
An independent certified internal auditor (CIA) can play a crucial role in addressing the problem of Healthplans gaming providers. By conducting thorough, unbiased audits and implementing robust oversight mechanisms, independent CIAs can help ensure fairness, transparency, and compliance with contractual and regulatory requirements. Here are several ways an independent CIA can address this issue:
Key Strategies for Internal Auditors
1. Regular and Comprehensive Audits:
Conduct Thorough Reviews: Perform regular audits of health plan contracts, payment structures, and provider interactions to identify any practices that may constitute gaming. This includes scrutinizing the terms of value-based contracts and the methods used to measure provider performance and patient outcomes.
Data Validation: Verify the accuracy of data submitted by health plans, including performance metrics, patient outcomes, and financial transactions. This ensures that the reported data reflects true performance and is not manipulated to meet contractual terms unfairly.
2. Transparent Reporting and Accountability:
Detailed Reports: Provide detailed audit reports to health plan management, the board of directors, and regulatory bodies. These reports should highlight any discrepancies, unethical practices, or areas where gaming is suspected.
Follow-Up Actions: Ensure that there are clear follow-up actions and corrective measures for any identified issues. This may include recommending changes to contract terms, improving data collection methods, or imposing penalties for non-compliance.
3. Stakeholder Engagement and Education:
Provider Feedback: Engage with providers to gather feedback on their experiences with value-based contracts and any perceived unfair practices. This information can be used to identify common issues and areas for improvement.
Training and Support: Provide training and support to Healthplan staff and providers on ethical practices, compliance requirements, and the importance of integrity in reporting. This helps build a culture of transparency and accountability.
4. Conflict of Interest Management:
Independent Oversight: Ensure that auditors maintain independence from the health plan’s operational management to avoid conflicts of interest. This can be achieved by reporting directly to the board or an independent audit committee.
Ethics and Compliance Programs: Implement robust ethics and compliance programs that include clear policies on conflict of interest and whistleblower protections. This encourages employees and Providers to report unethical practices without fear of retaliation.
5. Use of Advanced Analytics:
Detect Anomalies: Utilize advanced data analytics to detect patterns indicative of gaming, such as unusual spikes in certain diagnoses, abrupt changes in patient demographics, or discrepancies in performance metrics.
Predictive Modeling: Develop predictive models to identify potential areas where gaming might occur and proactively address these risks.
Practical Examples
1. Audit of Performance Metrics:
Case Study: An audit of a Healthplan's performance metrics might reveal that the benchmarks set for providers are unrealistically high, making it difficult for them to achieve bonuses. The auditor can recommend adjustments to these benchmarks to ensure they are fair and achievable.
2. Review of Reimbursement Practices:
Case Study: An independent auditor might discover that a health plan is delaying payments to providers without just cause. The auditor can highlight this issue in their report and recommend that the health plan implement a more timely and transparent payment process.
3. Provider Interviews and Surveys:
Case Study: Conducting interviews and surveys with providers can uncover widespread dissatisfaction with certain contract terms. The auditor can use this feedback to advocate for changes that make contracts more equitable and aligned with the providers' ability to deliver quality care.
An independent certified internal auditor (CIA) can play a crucial role in addressing the problem of health plans gaming providers. By conducting thorough, unbiased audits and implementing robust oversight mechanisms, internal auditors can help ensure fairness, transparency, and compliance with contractual and regulatory requirements. Here are several ways an independent CIA can address this issue:
References
Pathways To Success: Behavioral Health's Value-Based Care Journey.
https://healthcare.rti.org/insights/behavioral-health-value-based-care
DISCLAIMER and PURPOSE: This discussion document is intended for training, educational, and or research purposes only. The information contained herein is based on the data and perspectives available at the time of writing. It is subject to revision as new information and viewpoints emerge.
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