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OIG targets nursing homes in 2012

April 23, 2012
by Bob Gatty
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The Office of Inspector General (OIG) in the Department of Health and Human Services has an ambitious work plan underway for 2012, one that promises to affect many LTC facilities and hospices across the nation.

Here’s a thumbnail of key initiatives that will be, or are already being, taken by the OIG:

  • Medicare Requirements for Quality of Care in Skilled Nursing Facilities—OIG will review how SNFs have addressed federal quality of care requirements and will determine the extent that such facilities have developed plans of care based on assessments of beneficiaries, provided services to beneficiaries in accordance with those plans, and planned for beneficiaries’ ischarges.                                                                                                   
  • Safety and Quality of Post-Acute Care for Medicare Beneficiaries—OIG will review the quality of care and safety of Medicare beneficiaries transferred from acute-care hospitals to post-acute care. The agency will evaluate the transfer process and identify rates of adverse events and preventable hospital readmissions from post-acute settings. 
  • Nursing Home Compliance Plans—OIG will review Medicare and Medicaid certified nursing homes’ implementation of compliance plans as part of their day-to-day operations and whether the plans contain elements identified in OIG’s compliance program guidance.
  • Oversight of Poorly Performing Nursing Homes—OIG will assess CMS’ and states’ use of enforcement measures to determine their impact on improving the quality of care that beneficiaries received in poorly performing nursing homes and evaluate the performance of these nursing homes. The agency will determine the extent to which CMS and states follow up to ensure that poorly performing nursing homes implement correction plans.
  • Nursing Home Emergency Preparedness and Evacuations During Selected Natural Disasters—OIG will review nursing homes’ emergency plans and emergency preparedness deficiencies cited by state surveyors to determine the sufficiency of these plans and their implementation. OIG will describe the experiences of selected nursing homes, including challenges, successes and lessons learned when they implemented their plans during recent disasters, such as hurricanes, floods and wildfires.
  • Medicare Part A Payments to Skilled Nursing Facilities—OIG will review the extent to which payments to SNFs meet Medicare coverage requirements. A medical review will be conducted to determine whether claims were medically necessary, sufficiently documented and coded correctly during calendar year 2009.
  • Hospitalizations and Rehospitalizations of Nursing Home Residents—OIG will review the extent to which Medicare beneficiaries residing in nursing homes have been hospitalized and rehospitalized. The agency will assess CMS’ oversight of nursing homes whose residents have high hospitalization rates.
  • Questionable Billing Patterns –OIG intends to identify questionable billing patterns associated with nursing homes and Medicare providers for Part B services provided to nursing home residents whose stays are not paid for under Medicare’s Part A SNF benefit. Part B services during a non-Part A stay must be billed directly by suppliers and other providers.

In addition, OIG said it would take the following actions with respect to hospices:

  • Hospice Marketing Practices and Financial Relationships with Nursing Facilities—OIG plans to review hospices’ marketing materials and practices, as well as their financial relationships with nursing facilities. In a recent report, OIG found that 82 percent of hospice claims for beneficiaries in nursing facilities did not meet Medicare overage requirements. The Medicare Payment Advisory Commission (MedPAC) has noted that hospices and nursing facilities may be involved in inappropriate enrollment and compensation, and has highlighted instances in which hospices aggressively marketed their services to nursing facilities.
  • Medicare Hospice General Inpatient Care—OIG will review the use of hospice general inpatient care from 2005 to 2010. The agency will assess the appropriateness of hospices’ general inpatient care claims and hospice beneficiaries’ drug claims billed under Part D. The agency said it will review hospice medical records to address concerns that this level of hospice care is being misused and to determine the extent to which drugs are being inappropriately billed to Part D. 

Bob Gatty has covered governmental developments for the trade and business press for more than 30 years. He is founder and president of G-Net Strategic Communications, Sykesville, Md.

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