Use of Monitors in Licensing and Disciplinary Proceedings

This week, we will look at how monitors can be used as a solution in licensing and disciplinary proceedings and a hypothetical situation where a state Medicaid Fraud Control Unit finds a provider billing for an unusually high number of patients or procedures per day. Through an investigation, the state unit finds poor documentation that looks like fraud.

How Can an Independent Integrity Monitor Serve as an Overall Part of a Resolution?

Initially, such a settlement will allow the provider or clinic to continue to practice, which is important for Medicaid providers. Keeping a Medicaid practice open is often crucial in some areas, especially those where there are very few Medicaid providers. While helping a Medicaid provider remain open is important, it not only impacts the person whose business it is, but it is also is critical for the community at large.

Keeping or bringing up such a health care provider to professional standards is also important.

Finally, it is critical all the way around to keep the pressure on the provider to make the promised changes to fix the system, and it protects the public by bringing the provider in line with professional standards.

The next scenario occurs where someone makes a complaint to a licensing board, the complaint is investigated and the licensing board finds, among other things, that the practitioner’s patient records lack basic elements: for example, adequate notes about treatments.

Oftentimes a complaint is made to a state regulatory agency – a licensing board, for example. It might be a dental board, or a medical board or a chiropractic board.

Most of these licensing boards have regulations that say what should be included in patient records at a minimum; this is the standard you would hope any kind of medical provider is recording in writing.

Here, an independent integrity monitor can be an excellent option, as it allows the health care provider to continue to practice while providing prompt feedback to the agency about whether the health care provider is making promised changes. While a straight suspension may hit the pocketbook, it does not help the provider make meaningful change in their health care practice. Yet there is an equal – if not greater – benefit to the health care provider, as the independent integrity monitor can provide tailored advice about how to bring the practice up to professional standards.

My colleague Catherine Keyes provides a simple, yet straightforward example of how this works in practice. She once saw the difference between having a chiropractor’s friend act as a monitor and write an overly simplistic report – “the charts look fine” – and the in-depth feedback given by professional monitors: “the history of present illness needs to be more complete, including info about the effectiveness of other treatments received.”

We have used the approach of an independent integrity monitor as a solution for remediating physicians in the opioid crisis. In this case, we could allow an independent integrity monitor to track prescriptions and prescribers of opioids and other drugs.

As part of a multi-pronged approach to the opioid abuse issue, many states are looking to see who their high prescribers are and whether these are legitimate practices or just pill mills.

A monitor can help a provider to put policies and procedures in place to

1. assess the underlying need for pain medication;
2. determine whether someone is actually taking the medications;
3. refer to other specialists for supplemental care: physical therapy, acupuncture, pain clinics; and
4. appropriately terminate care of patients who appear to be getting prescriptions primarily to re-sell the pills.

Yet the benefits do not end there; as part of settlement agreement, monitoring could require the provider to reduce the number of pain patients served and the quantity of pills prescribed over a certain period.

An independent integrity monitor can keep regulators informed, as most state agencies do not have the staff available to track compliance with the details of such an agreement.

As many of you know by now, independent monitoring is paid for by the licensee. Such use of a monitor also works to protect the public by bringing the professional in line with national standards for assessment, treatment and follow-up for pain patients.

In closing, using a monitor can allow the provider to remain open and demonstrate their commitment to improved practice. Health care providers are quick learners and, in some cases, putting a structured program in place is a relief.

Please join me next week when we consider how an independent integrity monitor can be used in nondisciplinary administrative proceedings.

In case you missed the earlier installments of this ongoing series, please see the links below.

Everything You Always Wanted to Know About Monitors But Were Afraid to Ask

Part 1, Part 2, Part 3, Part 4 and Part 5

Potential Issues in Corporate Monitorships

Part 1, Part 2, Part 3, Part 4 and Part 5

Suspension and Debarment in Monitoring

Part 1, Part 2, Part 3, Part 4 and Part 5

Monitoring in the Health Care Sector

Part 1, Part 2