Auditing of Low-Value Services: Following the Trends of Medicare FFS Claims

By
Original story posted on: June 14, 2021

An examination of areas of focus to reduce wasteful healthcare spending on services with little to no clinical benefit, and finding opportunities in improving the quality of care.

“Low-value care” is a common term, quite frequently used in discussions of healthcare spending and patient quality of care for some time now. More action has been taken on the issue of late, as we have seen an increase in consistent efforts made to reduce the use of low-value services in clinical settings.

No single factor drives the use of low-value services by providers, but rather it is a combination of several different causes, such as established clinical practices and workflows, information disparities, patient expectations, litigation concerns, and fee-for-service payment systems. The fact is, a staggering amount of healthcare is considered non-essential. To put it into perspective, over one-fifth of all medical care may be unnecessary, according to several studies and surveys of physicians.

Though the issue of low-value care is a global one, the problem of overspending and underperforming in healthcare is most significant here in the United States. The U.S. spends more on healthcare per capita and as a percentage of GDP than any other country, upwards of $340 billion per year. However, we do not see outcomes proportionate to that spending.

With pressure to reduce costs and improve quality for Medicare programs and throughout the U.S. healthcare system, reducing the use of low-value services must be a priority for providers and patients.

To tackle the issue and design a successful resolution strategy, a comprehensive understanding of low-value care and its impact on health outcomes is essential to identifying and ultimately reducing its occurrence in healthcare.

Defining Low-Value Services

To address the issue of low-value care, there must be agreement on what would be considered a low-value service. Low-value care is typically defined as medically unnecessary services, providing no health benefits to patients, incurring unnecessary costs to patients, or wasting limited healthcare resources. In some cases, low-value care can be harmful to the patient and/or lead to further unnecessary testing or treatment.

A recently formed Task Force on Low-Value Care, comprised of leading purchasers, patient advocates, employer coalitions, and other healthcare stakeholders, identified a list of the top five low-value clinical services. The services on the list were deemed common, unsafe, failing to improve health, or a combination of those traits. In addition, the services were selected based on several variances, such as their association with direct and indirect harm, their cost, and their prevalence. 

The Task Force suggests that organizations prioritize its recommendations in their efforts to identify, measure, and reduce low-value care. The top five services identified are:

  • Diagnostic testing and imaging for low-risk patients prior to low-risk surgery;
  • Population-based vitamin D screening;
  • Prostate-specific antigen (PSA) screening in men 75 and older;
  • Imaging for acute low-back pain for the first six weeks after onset, unless clinical warning signs are present (red flags); and
  • Use of more expensive branded drugs when generics with identical active ingredients are available.

It is recommended that individual health providers determine their specific low-value services, starting with a peer review. Identifying and minimizing low-value care could lead to substantial savings quickly, and create opportunities for increased expenditures on high-value services.

Efforts to Reduce Low-Value Services.

Healthcare organizations throughout the nation are increasingly implementing initiatives to reduce their use of unnecessary services and overtreatment, given the high cost and potential harm of low-value care.

Many different approaches can be taken in order to tackle the issue. However, here are a few foundational strategies for reducing low-value services: 

  • Awareness Campaigns: Leadership can inform staff of recommendations to promote a decrease in unnecessary tests and procedures. It can also be valuable to give patients access to educational resources that include questions to ask their physicians.
  • Lead with Value-Based Care: The use of value-based care models has proven to be the principal element to achieve quality care, patient satisfaction, and a successful healthcare process overall.
  • Work from Clinical Guidelines and Care Standards: Implement policies and procedures that support clinical guidelines and provide clinicians with resources for definitive quality measures. It can be helpful to distinguish specific services that require further review prior to ordering.

There are several different ways to reduce low-value health services. As a whole, the healthcare community is making significant progress in tackling the issue, with national education and awareness campaigns and an increased focus on reducing healthcare waste. However, we have a long way to go.

Ultimately, healthcare providers must prioritize eliminating waste to achieve the true transformation needed in the quality and cost-efficiency of health services. 

Programming Note: Listen to Susan Gatehouse report this story live today during Talk Ten Tuesdays, 10 Eastern.

Susan Gatehouse, RHIT, CCS,CPC, AHIMA-Approved ICD-10-CM/PCS Trainer

Susan Gatehouse is the founder and chief executive officer of Axea Solutions. An industry expert in revenue cycle management, Gatehouse established Axea Solutions in 1998, and currently partners with healthcare organizations across the nation, to craft solutions for unique challenges in the dynamic world of healthcare reimbursement and data management.

Related Stories

  • The Cares Act: Calling All Auditors
    This program could be a windfall for accountants, but also a huge bottleneck.The Provider Relief Fund (PRF) became law as part of the Coronavirus Aid, Recovery, and Economic Security (CARES) Act on March 27, 2020. The U.S. Department of Health…
  • Coding Audits: A Compliance Necessity
    Coding audits provide insight into the process of coding itself. The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has developed several healthcare compliance programs, and within the key elements of these programs you will…
  • CMS Announces the Resumption of Medicare Audits
    The hiatus of audits was short-lived.  The ongoing COVID-19 pandemic and resulting public health emergency (PHE) has brought about massive and quick changes in the healthcare industry, notably among them the temporary suspension of Medicare Fee-For-Service (FFS) audits. The Centers…