Unannounced survey may follow quality infractions
December 1, 1997 2 minutes read
Unannounced survey may follow quality infractions
JCAHO clarifies its stance
An allegation of fraud by a federal agency is not enough to spur a for-cause, unannounced survey by the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, says Janet McIntyre, JCAHO spokeswoman.
"The key is quality of care, not just financial fraud allegations," she says. The organization’s policy reads as follows: "If there are allegations of financial fraud that suggest that the quality of care might be affected, the Joint Commission will take quick action to investigate. Depending on the seriousness of the issue, the Joint Commission can perform a for-cause, unannounced survey."
Hospital Peer Review asked McIntyre under what circumstances fraud allegations would raise questions regarding quality of care. The following scenarios describe actions taken for financial reasons, but which ultimately affect patient care:
• Providing and billing for medical services not needed.
This means an organization is not only billing for unnecessary services, but it has actually provided for the patient something he did not need.
• Discharging a patient on a date that reflects the expiration of insurance of length of stay for DRG, despite the fact the patient needed additional treatment.
• Keeping a patient until insurance payments are exhausted (if on a daily rate rather than a capitated rate) even though the patient no longer needs to be there.
McIntyre cites upcoding as an example of a financial fraud allegation that might not call quality of care into question. In that case there’s no suggestion the organization hasn’t provided proper care for its patients.
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