OIG: Skilled Nursing Activities in the 2013 Work Plan

On October 2, 2012, The U.S. Department of Health and Human Services Office of the Inspector General (“OIG”) released its Work Plan for 2013. The OIG releases its work plan for each year in advance of the coming year. The work plan provides stakeholders in the health care industry with a broad overview of the OIG’s activities in the coming year as they relate to its enforcement priorities and issues it will review and evaluate during that fiscal year. This client alert is the second in a series of alerts that will outline the OIG’s activities, as discussed in the 2013 Work Plan, for a specific industry sector – Nursing Homes.

The OIG’s activities relating to Nursing Homes for 2013 are focused on quality of care, although investigations concerning questionable billing patterns are once again identified as a priority.

Quality of Care – Office of Evaluation and Inspections (“OEI”) Reviews.

OEI is going to review the incidence of adverse and temporary harm events for beneficiaries receiving post-acute care in nursing homes, and estimate the extent to which the harm was preventable. This is a repeat item from the 2012 Work Plan, and is being driven by the staggering growth in Medicare expenditures for skilled nursing facility (“SNF”) care. Medicare paid $12 billion for SNF care in 2000, and more than $28 billion in 2011.

OEI is also going to review the extent to which SNFs are using Resident Assessment Instruments to develop care plans and to provide care in accordance with such plans. Previous OIG reports indicate significant shortcomings in this regard, which is a violation of federal laws.

Quality of Care – Surveys and Corrective Action.

Federal regulations require nursing homes to submit plans of correction to address deficiencies identified during surveys. Previous OIG reports indicate that some state agencies are not properly verifying correction of identified deficiencies. As the OIG pressures state agencies to become more diligent, nursing homes should be prepared for increased scrutiny to trickle down to their implementation of plans of correction.

Similarly, the OIG plans to monitor poorly performing nursing homes to determine the extent to which states’ are employing enforcement measures designed to improve quality of care. This is a repeat item from the 2012 Work Plan.

Quality of Care – Identifying Outliers.

In 2007, the OIG found that 35% of hospitalizations during SNF stays were caused by poor quality of care or fragmentation of services. Since then, the OIG has expressed its desire to identify facilities with abnormal hospitalization rates and minimize preventable hospitalization. This is another repeat item from the 2012 Work Plan.

In a new effort to identify outliers and improve quality, the OIG expressed its plan to review the administration of antipsychotic drugs to beneficiaries in SNFs. This review will include comparing the percentage of residents receiving antipsychotic drugs in a given facility, and seeking to draw conclusions concerning the characteristics associated with facilities that demonstrate an above-average usage of antipsychotic drugs.

Questionable Billing.

In the 2013 Work Plan, the OIG expressed its continued focus on the extent to which ancillary providers bill Medicare Part B for services provided to residents in non-Part A stays. Congress has directed the OIG to monitor these types of claims for abuse. Particular areas of focus will include podiatry, ambulance, laboratory, and imaging services.

Compliance with Minimum Data Set (“MDS”) Requirements.

SNFs are required to submit to the State MDS data for all residents at specified intervals. This data is then sent to CMS, which uses it for a number of programs, including payment and quality monitoring. The OIG plans to evaluate the extent to which CMS and States oversee the accuracy and completeness of MDS data.

For more information on the OIG’s 2013 Work Plan, Medicare and Medicaid program integrity initiatives in general or assistance with responding to an OIG or OEI inquiry relating to any issue, please contact a member of Benesch’s Health Care Department:

Daniel J. O’Obrien at at 216.363.4691 or dobrien@beneschlaw.com

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