Annals of Health Law
READY OR NOT
billing errors are discrete, quality reporting errors can create systemic
problems and corrupt cumulative quality performance scores.265
Reimbursement for reporting programs including VBP occurs at the end of
a reporting year based on an entire set of reported codes as opposed to
payment on an ongoing basis for individual claims.266 Any fraud issues
pertaining to the data upon which payments were based jeopardizes the
entire payment; as such, incorrect data could compromise the integrity of
the scores for individual quality measures, multiple quality measures and/or
the Total Performance Score267 upon which reimbursements are based.268
As noted previously in the discussion regarding risk of fraud arising out
of VBP programs,269 maintaining and ensuring the integrity of quality data
generated and submitted to CMS is critical to avoiding liability under the
FCA. Compliance departments are instrumental in monitoring data quality
and validity.270 Compliance professionals should maintain a role in
reviewing patient population data for the designated VBP performance
periods to make sure all patients that fall within the various quality measure
criteria are in fact included. Corporate compliance should maintain robust
processes to identify gaps or inaccuracies in quality data and analyze the
issues with clinical quality and staff.271 These oversight mechanisms might
be best accomplished through structured validation reviews. The primary
purpose of validation reviews is to ensure that the quality data could be
recreated under auditing circumstances.272 Ensuring the integrity of quality
data before submitting it to CMS is consistent with the OIG’s emphasis on
employing internal procedures that screen for improper claims prior to
filing, and may protect against FCA liability.273
Moreover, in light of the evolving landscape for quality measurement
and reporting, it is important that providers develop an infrastructure to
track and manage the proliferation of quality measures. Compliance
professionals should evaluate and prioritize the clinical quality measures in
the context of an overall quality strategy.274 In particular, such a strategy
265. See Daniel F. Shay, Physician and Hospital Quality Reporting Fraud: Risk and
Compliance Methods, HEALTH LAW HANDBOOK section 3. 4 (Alice G. Gosfield, ed., 2010),
available at http://www.gosfield.com/PDF/Shay.QualityReportingFraud.pdf.pdf.
266. See id.
267. See Section IB, supra footnotes 55-59 and accompanying text.
268. See Shay, supra note 265, at 10-11.
269. See supra Section II.
270. See Thorpe, supra note 164, at 33.
271. See Shay, supra note 265, at 10; see also Watt & Chase, supra note 95, at 18
(recommending auditing and monitoring of quality measures).
272. See Watt & Chase, supra note 95.
273. See COMPLIANCE REPORT, supra note 250.