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OIG: Nursing homes provide ‘criminally poor care,’ fail on care plans

February 28, 2013
by Pamela Tabar, Senior Editor
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Skilled nursing facilities (SNFs) failed to meet their own basic care plans for more than one-third—37 percent—of their beneficiary stays, according to a recent report based on 2009 data released by the Office of Inspector General. Another 31 percent of SNFs didn’t meet required discharge planning requirements. Medicare paid about $5.1 billion in claims for stays in which SNFs didn't comply with one or both of these documentation categories.

The report adds yet another facet to ongoing federal investigations of both billing errors and outright billing fraud within nursing homes. The OIG has previously released data showing that 25 percent of SNF claims in 2009 contained errors, and that a worrisome number of SNFs are “upcoding”—billing federal agencies for more expensive care than they are delivering to beneficiaries.

In recent months, the Department of Justice and Health and Human Services has uncovered scandals aplenty: From an Ohio rehabilitation facility accused of billing for medically unneccessary therapy, to widespread off-label use of antipsychotic medication, to a Georgia nursing home chain that received $33 milion in Medicare and Medicaid funds, yet didn’t feed its 400 residents properly or fix leaking roofs. Deep inspection of medical records and billing claims have revealed alarming instances of “criminally poor care” in SNFs, notes an OIG spotlight article.

The care plan gaps, although not as dramatic as deliberate fraud or negligence, are still an enormous concern for the Centers for Medicare & Medicaid Services (CMS). Proper care plans contain measurable goals and MDS coding support to show what care is needed—and to document what Medicare is paying for. Discharge planning contains the resident’s condition at discharge and provides a post-discharge care plan, completing the final mile before discharging a resident to another facility or back home—documentation that would be crucial to answer a discharged resident’s questions ex post facto, or to combat responsibility should the resident end up being readmitted to a hospital.

If you think CMS’ scrutiny of SNFs has been strong lately, it could get even tighter. The OIG report recommends that CMS implement stricter oversight of SNFs, especially concerning the fulfillment of care plans and discharge goals. In addition, the report strongly urges CMS to tie payments to quality care requirements by adding care-plan regulations and using methods “beyond the State survey and certification process to promote compliance and make improvements in the areas of care planning and discharge planning,” the report states.

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