The Office of the Inspector General’s FY 2017 Work Plan contains a significant number of reports that are expected to be issued in FY 2017 related to post-acute and long term care providers. Historically, when the OIG issues reports, they serve as a reminder to CMS that they have improvements to make in those areas, so these are some things to be on the lookout for in the next few months.
Nursing Facilities
- Potentially Avoidable Hospitalizations of Medicare- and Medicaid-Eligible Nursing Facility Residents: Hospitalizations of nursing facility residents can be indicative of poor quality of care. OIG will review nursing facilities with high rates of hospital transfers for potentially preventable conditions and to determine whether nursing homes provided services in accordance with residents’ care plans.
- Skilled Nursing Facility Reimbursement: OIG has previously found that SNFs bill for higher levels of therapy than necessary. This report will review documentation to see if it meets the requirements for the RUG category selected.
- Skilled Nursing Facility Prospective Payment System Requirements: OIG has previously found that Medicare payments for SNF services were not compliant with the 3-day inpatient hospital stay within 30 days of a SNF admission. This report will review compliance with the SNF PPS requirement related to the qualifying hospital stay.
- Skilled Nursing Facility Adverse Event Screening Tool: The SNF adverse event trigger tool report will explain the purpose, use and benefits of the tool for the SNF industry. Adverse events are a key focus of the QAPI initiative, which is part of the Phase 2 RoPs.
- National Background Checks for Long–Term-Care Employees – Mandatory Review: OIG will review the processes for states that are using these background checks for prospective employees that would be direct care staff. This report will identify if the checks led to any unintended consequences.
Home Health Services
- Comparing HHA Survey Documents to Medicare Claims Data: Since HHAs provide patient information to surveyors but SAs do not have access to Medicare claims data to verify the information, there may be a possibility of fraudulent behavior. OIG will review whether home health agencies are accurately providing patient data to State Agencies during their recertification surveys.
- Home Heath Compliance with Medicare Requirements: OIG and CMS reporting have shown significantly high payment error rates at HHAs, primarily for patients who did not require skilled services or who were not homebound. This report will review compliance with various aspects of the home health PPS and include medical review of the required documentation to support Medicare claims to determine if they were paid in accordance with Federal requirements.
Home Health Services and Other Community-Based Care
- Data Brief on Fraud in Medicaid Personal Services: OIG will present a data brief that will include information on the prevalence of fraud and patient abused or neglect in personal care services.
- Adult Day Health Care Services: Prior OIG work has found that Medicaid payments for adult day health care services do not always comply with State and Federal requirements. OIG will review Medicaid payments by states for these services to determine whether providers complied with requirements.
State Claims for Federal Reimbursement
- State Agency Verification of Deficiency Corrections: A prior OIG report found that one SA reviewed did not always verify that nursing homes corrected deficiencies identified on survey in accordance with Federal requirements. OIG will determine whether State Agencies verified correction plans for deficiencies identified on nursing home recertification surveys through on-site reviews or by obtaining other evidence of correction.
- Medicaid Beneficiary Transfers from Group Homes and Nursing Facilities to Hospital Emergency Rooms: Like the report listed above, “Potentially Avoidable Hospitalizations of Medicare- and Medicaid-Eligible Nursing Facility Residents,” OIG will review the rate of and reasons for transfer from group homes or nursing facilities to hospital emergency departments. These ER transfers may be indicative of poor quality of care.
Read the full HHS / OIG Work Plan for FY 2017 here.