The billing, hiring, care-provision and deficiency-correction practices of nursing homes, hospices and home health programs are among the areas to be targeted by the U.S. Department of Health and Human (HHS) Services Office of Inspector General in 2015, according to a new work plan issued by the OIG.
- Medicare Part A billing by skilled nursing facilities (SNFs). The OIG expects to release a report describing changes in SNF billing practices from 2011 to 2013. Earlier work by the office found that SNFs increasingly billed for the highest level of therapy although beneficiary characteristics did not change much, the work plan notes, and also found that one-fourth of claims by SNFs in 2009 were billed in error, at a cost of $1.5 billion in inappropriate Medicare payments. The Centers for Medicare & Medicaid Services (CMS) since has changed how SNFs bill for services for Medicare Part A stays.
- Questionable billing patterns for Part B services during nursing home stays. The OIG plans to identify questionable billing patterns associated with nursing homes and Medicare providers for Part B services provided to residents during stays not paid under Part A (for example, stays during which benefits are exhausted or the three-day prior-inpatient-stay requirement is not met). Through a series of studies, the OIG will examine several broad categories of services, among them foot care. Congress directed the OIG to monitor Part B billing for abuse during non-Part A stays to ensure that no excessive services are provided, the work plan notes.
- State agency verification of deficiency corrections. The OIG expects to determine whether state survey agencies verified correction plans for deficiencies that were identified during nursing home recertification surveys. A previous OIG review found that one state survey agency had failed in this regard, not meeting federal requirements that specify that nursing homes must submit correction plans to the state survey agency or to CMS, the work plan notes. CMS requires state survey agencies to verify the correction of identified deficiencies through onsite reviews or other evidence.
- Program for national background checks for long-term-care (LTC) employees. The OIG plans to review the procedures that participating states have implemented for LTC facilities or providers to conduct background checks on prospective employees and providers who would have direct access to residents and determine the costs of conducting such background checks. The OIG will examine whether the programs led to any unintended consequences.
- Hospitalizations of nursing home residents for manageable and preventable conditions. The OIG expects to determine the extent to which Medicare beneficiaries living in nursing homes are hospitalized as a result of conditions thought to be manageable or preventable in the nursing home setting. A 2013 review by the OIG found that one-fourth of Medicare beneficiaries were hospitalized for any reason in fiscal year 2011. Hospitalizations of nursing home residents are costly to Medicare and may indicate quality-of-care problems in nursing homes, the work plan notes.
- Hospice programs in assisted living facilities (ALFs). The OIG plans to review the extent to which hospices serve Medicare beneficiaries who reside in assisted living facilities (ALFs) in regards to length of stay, levels of care received and common terminal illnesses of beneficiaries. This review is expected to help CMS meet a requirement under the Affordable Care Act to reform the hospice payment system, collect data relevant to revising hospice payments and develop quality measures for hospices. ALF residents have the longest lengths of stay in hospice care, according to the work plan, and MedPAC has said that these long stays should be further monitored and examined.
- Hospice general inpatient care. The OIG expects to review and assess the appropriateness of hospices’ general inpatient care claims and the content of election statements for hospice beneficiaries who receive general inpatient care. Also, the office will review hospice medical records to address concerns that this level of hospice care is being misused.
Home health services
- Home health prospective payment system (PPS) requirements. The OIG plans to review compliance with various aspects of the home health PPS, including the documentation required to support claims paid by Medicare, to determine whether home health claims were paid according to federal laws and regulations. Previously, the OIG found that one-fourth of home health agencies had questionable billing. Since 2010, nearly $1 billion in improper Medicare payments and fraud has been identified relating to the home health benefit, the OIG work plan notes.
- Employment of workers with criminal convictions. The OIG expects to determine the extent to which home health agencies employed people who have been convicted of crimes and also will examine the criminal convictions of selected employees with potentially disqualifying convictions. Most states have laws prohibiting certain healthcare-related entities from employing people who have certain types of criminal convictions, the work plan notes.