Compliance and quality are often viewed as two distinct functions. Typically, compliance deals with the rules and proper procedures for billing Medicare and other third-party payers. Conversely, quality functions do not usually concern themselves with reimbursement. A traditional quality assurance function focuses on the nature of the care provided to the patient. Increasingly, however, these two functions are becoming interrelated as good quality is often a prerequisite to effective compliance.
The emphasis on quality is exhibited in health care reform measures, specifically the Patient Protection and Affordable Care Act, which encourages development of accountable care organizations (ACOs) and evidence-based medicine. The legal line between compliance and quality, however, has not always been clear. Efforts to use quality as a potential False Claims Act (FCA) violation have thus far not been extremely effective in strengthening the connection between compliance and quality of care.
Efforts to Use Quality Under the FCA
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