The Office of Inspector General, U.S. Department of Health and Human Services (OIG) has implemented a work plan affecting long-term care, specifically, nursing home and skilled nursing facilities. JD Supra highlights some of the focus areas of this initiative, which affect both payments and performance issues.
Focus on quality of care
In terms of quality of care, nursing homes are required to utilize the Residential Assessment Instruments (RAI) to create a plan of care for each resident and plan for eventual discharge. However, reports have indicated that about 25 percent of residents' needs are not addressed in their care plans and residents are not receiving psychosocial services which are addressed in their care plans.
The OIG has also made state inspections a priority. Specifically, whether state agencies are following up on correction plans created in response to deficiencies identified during state nursing home inspections. There will also be a focus on the efforts of state agencies and the Centers for Medicare and Medicaid Services (CMS) to improve performance. Enforcement decisions, including follow-up actions and the implementation of corrective measures in response to complaints and survey results are a core focus in this area.
Focus on billing and payments
A number of focus areas have also been identified in relation to billing and payments. There will be increased scrutiny on both Medicare Part A and Medicare Part B claims submitted by providers with a history of billing errors. CMS will have the ability to deny a provider's enrollment in the Medicare program if they're found to have existing overpayments that they've failed to refund.
Medicaid overpayments will also be in focus: Medicaid is intended to be "the payor of last resort," and providers are supposed to identify and refund overpayments. OIG will be reviewing patient accounts which have credit balances to identify and reclaim any overpayments found. State procedures for identifying and collecting third-party payments will also be reviewed, as these procedures can help avoid overpayments in the first place.
Hospice programs, and the relationship between hospice providers and nursing facilities, will also be scrutinized in light of findings that up to 82 percent of hospice claims for patients residing in nursing homes did not meet Medicare eligibility requirements. There have also been reports and findings that some hospice providers have aggressively marketed their services or have entered into inappropriate enrollment and compensation in conjunction with contracted nursing facilities.
Questionable billing patterns have also been identified in relation to Medicare Part B benefits for nursing home residents. Medicare Part B services must be billed directly by suppliers or other providers. The OIG will investigate these patterns to identify areas of inaccuracy.
These are just a few of the items addressed in the OIG's Work Plan that will affect long-term care providers. These focus areas will place added responsibilities on both state agencies and CMS, as well as providers, although the implementation of these measures will serve to improve the quality of care received by residents and preserve funds that can help maintain the viability of Medicare and Medicaid programs.