American College of Physicians: Internal Medicine — Doctors for Adults ®

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Proposed PRO 'bounty system' could hurt PRO-doctor relationship

From the February 1999 ACP-ASIM Observer, copyright 1999 by the American College of Physicians-American Society of Internal Medicine.

Several new peer review organization (PRO) policies proposed by HCFA this fall could undermine the cooperative relationship that has developed between PROs and the medical community in recent years, ACP-ASIM President Harold C. Sox, FACP, said in a letter to HCFA Administrator Nancy-Ann Min DeParle.

ACP-ASIM is particularly concerned about a proposed payment error prevention program (PEPP) designed to reduce payment errors in Medicare inpatient prospective payment services. HCFA's PEPP proposal would make PROs responsible for tracking payment errors and for denying payments in cases where there is questionable justification for a payment. PROs would be able to refer these cases to fiscal intermediaries and to law enforcement officials.

Under the HCFA proposal, PROs could receive bonuses for helping achieve decreases in payment error rates. In his letter, Dr. Sox described HCFA's proposal linking the detection of fraud with financial incentives as the equivalent of a "bounty system."

According to the College's letter, HCFA should redesign the program to decrease payment errors by focusing on the same "quality improvement techniques that have succeeded to improve clinical care." The letter states that if a PRO detects improper payment patterns, for example, the PRO could work with local physicians and seek educational approaches to eliminate future billing errors.

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