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OIG Report – CMS Could Identify Potential Abuse/Neglect with Claims Data

The Office of the Inspector General (OIG) released a new audit report on June 12, 2019, “CMS Could Use Medicare Data To Identify Instances of Potential Abuse or Neglect.” This report was based on Medicare claims from January 2015 to January 2017 that included one or more of 17 diagnosis codes that OIG identified as potentially related to physical abuse, sexual abuse/rape, neglect, abandonment or other forms of maltreatment. The claims were not provider-specific, unlike reports the Agency has issued related specifically to skilled nursing facilities, but did include some healthcare settings. Highlights from the report include:

  • OIG identified nearly 35,000 Medicare claims that included information related to potential abuse or neglect. The report estimates that approximately 2,500 alleged perpetrators may have been healthcare workers, and estimates that more than 3,000 incidents took place in a medical facility. The OIG’s report details the findings of a stratified random sample of 100 claims. 
  • 12 of the 94 claims OIG reviewed were associated with potential abuse or neglect at a medical facility. These included nursing homes/SNFs (7), group homes (1), LTACHs (1) and assisted living facilities (1). 61 of the incidents occurred in the beneficiaries’ homes and 16 occurred in public settings or in other people’s homes.
  • Of the 100 claims reviewed, 94 indicated potential abuse or neglect. In those 94 cases, the majority of incidents involved family members (39) and spouses/significant others (20). For the other incidents, it was nearly a 50/50 split between the alleged perpetrator being known (14) and unknown (13) to the victim.

The OIG issued an Early Alert to the Centers for Medicare & Medicaid Services (CMS) in 2017 after identifying potential issues related to Medicare beneficiaries who were residing in SNFs and transferred to hospital Emergency Rooms. CMS took some actions as a result, but disagreed with three of four OIG recommendations from this report. For instance, while the OIG report found that more than 90% of its 100 claims reviewed contained evidence of potential abuse or neglect, CMS noted that more than 80% of the sampled claims were not in healthcare settings. However, CMS provided information on a multitude of actions that it is taken related to abuse and neglect. The Agency’s response includes several items related to nursing facilities:

  • CMS looked at creating a model based on SNF Patient Abuse after the OIG issued its early alert, but it was unable to create a model using claims data as recommended by OIG. Instead, CMS issued information about patient harm to organizations involved in program integrity, such as ZPIC auditors.
  • CMS stated that it recently updated its guidance on Immediate Jeopardy to help with the identification and prevention of situations of abuse and neglect. The Agency also stated that FOSS surveys for 2019 will focus on identifying concerns related to abuse and neglect, as well as facility staffing. Low staffing could result in increased numbers of these incidents, particularly where neglect is concerned, so while this is listed as a separate area of focus for the Regional Offices, it is connected to abuse and neglect as well.  
  • The Agency is also exploring how it can use claims data that includes specific diagnosis codes that indicate potential abuse or neglect in nursing homes and how that data can help to address potential incidents.
  • CMS concurred with OIG’s recommendation that it assess the sufficiency of Federal requirements and Section 1150B of the Act related to mandatory reporting of suspected abuse and neglect. CMS stated that it will review its CoPs and Interpretive Guidance to strengthen the existing language related to reporting of potential abuse or neglect to appropriate authorities including State Agencies and local law enforcement. Changes to Section 1150B of the Social Security Act, it noted, require an act of Congress in order to implement.

Read the June 12, 2019 OIG report (A-01-17-00513) here. You can also view CMSCG’s blog on OIG’s accompanying report, “Incidents of Potential Abuse and Neglect at Skilled Nursing Facilities Were Not Always Reported and Investigated” here.

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