Category Archives: Long Term Care

CMS Issues Updated Guidance on Fine Imposition and the Collection Process for Nursing Homes

On April 25, 2014, the Centers for Medicare and Medicaid Services (“CMS”) issued revision 113 to the State Operations Manual (“SOM”) governing skilled nursing and nursing facility survey and enforcement processes. Specifically, CMS updated the SOM Chapter 7 with an effective date of January 1, 2012 as the modifications were mandated by section 6111 of the Affordable Care Act of 2010. The major provisions related to guidance on the independent informal dispute resolution process; escrow of civil money penalty funds pending a formal appeal; a reduction of fifty percent (50%) for facilities that promptly correct self-reported non-compliance and guidance on the use of civil money penalty funds for the state agencies. As of today, the online CMS manual system does not include the updated guidance.

This guidance is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R113SOMA.pdf.

OIG 2014 Work Plan – Skilled Nursing Facilities

Recently, the Department of Health and Human Services Office of the Inspector General (the “OIG”) released its work plan for 2014. 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 the year. This article is one in a series of articles that will outline the OIG’s activities, as discussed in the 2014 work plan, for a specific industry sector – skilled nursing facilities.

For 2014, the OIG’s activities relating to skilled nursing facilities are focused on billing and payments and quality of care. Continue reading

Office of Inspector General Issues Strategic Plan

The Office of the Inspector General (“OIG”) issued a 2014-2018 strategic plan including outlining the visions, goals, and priorities of that office for the upcoming several years. The plan sets forth four goals: 1. Fight fraud, waste and abuse; 2. Promote quality, safety, and value; 3. Secure the future; and 4. Advance excellence and innovation. Each goals is identified with several priority areas that support the stated goal. The report can be found at the OIG’s website http://go.us.gov/WdbV

Hospitalizations High for Medicare Nursing Home Residents

The Office of the Inspector General (OIG) released a study on November 17, 2013 studying 2011 hospitalization statistics for Medicare nursing home residents. The report finds that one quarter of Medicare nursing home residents were hospitalized for at least one day in federal fiscal year 2011. The study also reports that Medicare costs for nursing home residents represent 11.4% of the Medicare Part A spending on all hospital admissions during that same year resulting in Medicare paying $126 billion for those stays. Interestingly, high hospitalization rates were not evenly distributed throughout the country and generally nursing homes with lower CMS quality ratings had higher hospitalization rates. OIG recommends to CMS the development of a quality measurement report hospitalization rates for residents in each nursing home and to publicly report such measures. You can find a copy of the study here —> SNF Hospitalization Study

CMS Directs MACs to Reject Part B Ambulance Claims for SNF to SNF Transfers

On November 6, 2013, CMS issued Transmittal No. 1311 which instructed Medicare Administrative Contractors (“MACs”) to reject claims for SNF to SNF ambulance transfers that are billed separately under Part B. According to CMS, ambulance transportation and related ambulance services for residents in a Part A stay are included in the SNF PPS rate and may not be billed as Part B services by the supplier. Instead, the SNF discharging the beneficiary to another SNF is responsible for the transportation fees. As such, ambulance providers must seek payment from the transferring SNF. Continue reading

NYS Identifies $496 Million in Medicaid Home Health Erroneous Payments

On October 30, 2013, the New York State Office of the Medicaid Inspector General (“OMIG”) issued a press release that New York recovered $211 million from the federal government out of an identified $496 million in Medicaid erroneous payments related to home care recipients who are dually eligible for both Medicare and Medicaid funds.  On October 1, 2013, the New York State Department of Health’s Fiscal Group received the $211 million payment through the action of OMIG, which was the largest single monetary recovery in OMIG’s history.

These payments were recovered by New York State as part of a federal project, the Third-Party Liability Home Health Care Demonstration Project, which is reviewing home health care involving dual eligible recipients, and is being conducted in conjunction with the University of Massachusetts Medical School.  Continue reading

CMS Issues Guidance on CPR in Nursing Facilities

The first Survey & Certification memo for nursing facilities was issued for Fiscal Year 2014 on October 1, 2013. S&C 14-01-NH requires nursing facilities to adopt a policy that implements basic life support measures such as basic CPR for residents in accordance with the individual resident’s advance directives. Some nursing facilities have previously adopted a policy that when a resident is found without vital signs and the resident was a full code, the facility called 911 and waited for a response from the emergency personnel. CMS has affirmatively stated that the facility implement CPR when cardiac arrest occurs for residents in accordance with their advance directives and merely waiting for emergency personnel to respond to the 911 call is inadequate. CPR certified staff must be available at all times to provide CPR when necessary. Facilities will be cited under F155 for violating a resident’s right to formulate an advance directive if the facility does not develop and successfully implement policies and procedures to assure that residents will be resuscitated in accordance with their individual advance directives.

You can find a copy of  the letter here —> S&C 14-01-NH

For more information on the Survey Letter or related issues, please feel free to contact Janet Feldkamp or any member of our health care practice group for a further discussion.