PYA White Paper Offers Guidance for Conducting Claims-Based Reviews of Inpatient Quality Reporting Data and the Link Between Payment and Quality

PYA has released a new white paper offering healthcare organizations guidance for conducting claims-based reviews in light of the U.S. Department of Health and Human Services Office of Inspector General’s review of hospital quality reporting.

PYA recently released a white paper, “Your Dollars Matter: Inpatient Quality Reporting and Healthcare-Acquired Infectionsto offer healthcare organizations guidance for performing claims-based reviews of inpatient quality reporting (IQR) data.  Based on the results of a U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) review, the white paper examines the connection between IQR data, payment, and quality.  The paper  emphasizes the importance auditors and compliance practitioners must place on reporting, and encourages results validation.

For some time, the OIG had been interested in determining to what extent the Centers for Medicare & Medicaid Services (CMS) validated hospital IQR data, particularly in reference to the Hospital Value-Based Purchasing (VBP) and Hospital-Acquired Condition Reduction Programs (HACRP).  The OIG’s review indicated CMS needs to use analytics to ensure the integrity of hospital-reported quality data and resulting payment adjustments for hospital-acquired infection (HAI) and process-of-care measures.

An excerpt from the white paper reads: “Previously, hospitals were overloaded with validating all their publicly reported quality data; however, the results of the 2017 OIG review provided hospitals with a focus area for their quality reporting compliance efforts. More than ever, organizations should plan for focused claims-based reviews as it is necessary for them to understand how [IQR] data links payment to quality and enables consumers to make informed decisions about their healthcare needs.”

As healthcare continues to move toward the use of a VBP system, it is imperative that healthcare organizations routinely monitor and test HAI data as part of a robust compliance program.


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