The U.S. Department of Health and Human Services (DHHS) Office of Inspector General (OIG) recently issued its Work Plan for Fiscal Year 2017. The annual Work Plan provides a summary of new, revised, and continuing reviews for DHHS programs and operations, including Medicare and Medicaid. It describes ongoing audits, evaluations and specific legal and investigative matters. The release of the Work Plan provides an opportunity for nursing facilities to review their own operations and practices while comparing them to the objectives in the Work Plan in order to identify areas for compliance improvement.
The OIG conducts investigative activities that involve allegations of fraud, waste and abuse in all of DHHS’s programs. Medicare and Medicaid constitute a significant amount of its work. Areas the OIG can investigate include billing for services not rendered, provision of medically unnecessary services and misrepresented services, patient harm, and the solicitation and receipt of kickbacks. In addition to performing investigations, the OIG is involved in legal matters including: the exclusion of individuals and entities from participation in Medicare, Medicaid, and other federal health care programs; false claims act cases; civil monetary penalties related to false claims; and corporate integrity agreements. The OIG will also issue advisory opinions and guidance to providers.
In the 2017 Work Plan, the OIG has added several risk areas and revised one for Skilled Nursing Facilities (SNF) and Nursing Facilities (NF) in the Medicare and Medicaid programs. The additional areas include unreported incidents of potential abuse and neglect and facility reimbursement.
Specifically, the OIG noted ongoing reviews in other settings indicated the potential existed for unreported instances of abuse and neglect. The focus will be to assess the occurrence of abuse and neglect of beneficiaries in skilled nursing facilities and determine whether the instances were reported properly and investigated according to federal and state requirements.
Also, there are some SNF patients that have complex nursing and therapy needs. Patients are classified into resource utilization groups for payment and generally, the more complex the needs, the higher the Medicare rate for the patient. The OIG noted earlier investigations found SNFs were billing for higher levels of therapy than were medically necessary or provided. The OIG’s focus will be to determine whether documentation exists demonstrating requirements were met for the level of therapy provided.
While the OIG added topics to its Work Plan, there are other areas that will continue to be a focus, including prospective payment system requirements and potentially avoidable hospitalizations of nursing facility residents. With respect to prospective payment systems, the OIG is continuing its focus on the requirement for a three-day qualifying inpatient hospital stay within 30 days of an SNF admission. Another focus area that will continue into 2017 involves potentially avoidable hospitalizations of Medicare and Medicaid nursing facility residents. The OIG is concerned with the high occurrence of patient transfers from nursing facilities to hospitals for potentially preventable conditions. It believes this could be an indication of poor quality of care. Nursing facilities with high rates of these types of patient transfers could be subject to OIG review.
In addition to ongoing work, the OIG included future planning efforts in its 2017 Work Plan. Specifically for SNFs, the OIG indicated planning efforts in the future will address oversight of compliance with patient admission requirements. The OIG did not provide any additional explanation regarding this future effort or clarify which admission requirements would be subject to examination.
What does this mean for you?
The OIG focuses its Medicare and Medicaid oversight on reducing improper payments, and preventing and deterring fraud, waste and abuse. The Work Plan provides insight into the areas that could come under scrutiny and ultimately can help guide internal compliance activities for your facility.
These audits and the increased focus serve as an important reminder that facilities must remain vigilant with their documentation. Also, it is essential that facilities are familiar with applicable requirements for the provision of services and remain current with policies, rules, and regulations. It is also a good time for SNFs and NFs to review their compliance plan and internal policies to verify they address all necessary requirements for the provision of services.
Facilities need to take steps now and review their operations to be better prepared for the current regulatory and audit environment, to minimize their chances for negative audit findings and importantly, to provide proper and quality care.