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OIG 2013 Work Plan: What Skilled Nursing Facilities, Hospice Providers and Home Health Agencies Need to Know

The new fiscal year is underway, which means the Office of the Inspector General (OIG) work plan for 2013 has also been published. Reviewing the OIG’s initiatives will provide you with a foundation for what your facility needs to be focusing on, as CMS and the State agencies will recognize the oversight being placed on these areas and adjust their actions accordingly. Whether you are a skilled nursing facility, hospice provider or home health agency, paying attention to the highlights below will help you with your focus for the next year.

  • Nursing Homes – Adverse Events in Post-Acute Care for Medicare Beneficiaries
    • The OIG will be looking at contributing factors, identification of preventable adverse events and will estimate the costs of such events to Medicare. This has been a focus of the OIG in previous work plans, and entails providing a nationwide incident estimate of beneficiaries receiving care in post-acute facilities.
  • Nursing Homes – Medicare Requirements for Quality of Care in Skilled Nursing Facilities
    • This has also been a focus of the OIG previously, but they expect to complete this project in FY 2013 and issue a report on Medicare Requirements for Quality of Care. Their focus here will be on care planning – how is your skilled nursing facility using the Residential Assessment Instruments (RAI) in developing the plan of care for residents? The OIG has reported in the past that nearly 25% of nursing home residents were not provided with the psychosocial services that had been put into their care plans.
  • Nursing Homes – State Agency Verification of Deficiency Corrections*
    • This is a new focus from the OIG, and they plan to report on this issue in FY 2013. Here, instead of checking with the nursing homes for compliance, they will be looking at the State survey agencies that are responsible for verifying that your Plan of Correction has been implemented as it was submitted. The SOM provides ways for the surveyors to verify that your deficiencies have been corrected, but the OIG has found previously that surveyors have not always been following up. Expect that surveyors will be doing more follow-up to ensure that your POC has been implemented as you promised.
  • Nursing Homes – Oversight of Poorly Performing Facilities
    • The oversight of nursing homes with performance issues has been a continued focus of CMS and the State agencies, and therefore has been a focus of the OIG as well. The OIG will take a look at the regulators’ use of enforcement measures as a means of helping skilled nursing facilities improve their performance. Since the OIG plans to do some deep digging into survey results and enforcement decisions, surveyors will be focused on ensuring they are following the requirements of the SOM and issuing deficiencies as accordingly.
  • Nursing Homes – Use of Atypical Antipsychotic Drugs*
  • Nursing Homes – Hospitalizations of Nursing Home Residents
    • Although the OIG has been looking at this in previous plans, a report is expected this year on preventable hospitalizations. The news has been full of information about the focus on preventing re-hospitalizations, and while this issue penalizes hospitals, nursing homes are also on the hook for providing adequate quality of care to keep residents in the nursing homes. The OIG will be looking at areas like staffing and quality of care for this report.
  • Nursing Homes – Questionable Billing Patterns for Part B Services During Nursing Homes Stays
    • With a continued focus on recovering Medicare funds, this OIG project will focus on the identification of questionable billing for Part B services, which are required to be billed directly by the suppliers and other providers, not the nursing homes.
  • Nursing Homes – Oversight of the Minimum Data Set Submitted by Long-Term-Care Facilities*
    • This project is a new one identified in the OIG’s 2013 work plan. Completeness of the Minimum Data Set (MDS) is an important focus for your facility, not only for reimbursement, but also for care planning. CMS Compliance Group President Linda Elizaitis took a look at the MDS in a guest article for About.com Assisted Living, and provides some strong reminders about why the MDS is so crucial. The OIG plans to review how CMS and the State agencies are providing oversight as to the completeness and accuracy of the MDS, so there’s one more reason to get your ducks in a row.
  • Hospice – Marketing Practices and Financial Relationships with Nursing Facilities
    • The OIG will continue to look into the relationships that hospice providers have with nursing facilities to ensure that the hospice provider’s claims meet Medicare coverage requirements.
  • HHAs – Home Health Face-to-Face Requirement*
    • A new project for the OIG focuses on a home health agency requirement that a face-to-face meeting is occurring between physicians and patients within 120 days, as the law requires. Previous OIG reports have shown that only 30% of Medicare beneficiaries received a visit from the doctor who had ordered the services for them.
  • HHAs – Employment of Home Health Aides with Criminal Convictions
    • This is another new project and the OIG will be assessing if HHAs are compliant with State requirements for criminal background checks of applicants and employees. Take a look at what is happening in your Human Resources Department related to these checks.
  • HHAs – States’ Survey and Certification: Timeliness, Outcomes, Follow up, and Medicare Oversight
    • The OIG continues to review the timeliness of re-certification and complaint surveys by State Agencies and Accreditation Organizations, as well as their outcomes and follow-up.
  • HHAs – Missing or Incorrect Patient Outcome and Assessment Data
    • OIG will continue to monitor data from the Outcome and Assessment Information Set (OASIS) to identify payments that were made without OASIS data being submitted or inconsistencies between the OASIS and billing codes.
  • HHAs – Medicare Administrative Contractors’ Oversight of Claims
    • In another effort to control Medicare funding issues, the OIG will be looking into the effectiveness of the actions of CMS and its contractors to prevent improper payments to a HHA as well as their handling of potential fraud issues.
  • HHAs – Home Health Prospective Payment System Requirements
    • The OIG will issue a report this year on its review of home health PPS compliance, including appropriate documentation to support Medicare claims.
  • HHAs – Trends in Revenues and Expenses
    • The OIG will also issue a report this year on revenues and expenses in home health care, as it has noted that HHA expenditures have increased significantly since its implementation in 2000.

While we have provided you with a brief overview of what’s in the OIG work plan, the best thing to do would be to ensure you have a read through the details on your own as well so you know what their focus will be. The OIG 2013 Work Planis available on their website for your reference.