OIG Releases 2014 Work Plan – Nursing Homes, HCBS and more

The Office of the Inspector General (OIG) issued its 2014 OIG Work Plan on January 31, 2014. The initiatives list for this plan is shorter than the 2013 version, but that doesn’t mean that nursing homes and other providers will be scrutinized any less. Late in November 2013, the OIG released its 2014-2018 Strategic Plan. This plan laid out four areas that the OIG plans to focus on for the next few years, including fighting fraud, waste and abuse, promoting quality, safety and value, securing the future and advancing excellence and innovation. It is very clear when looking at the 2014 Work Plan that the OIG is putting an emphasis on the “fighting fraud, waste and abuse” promise.

The initiatives proposed include:

  • Medicare Part A billing by skilled nursing facilities – This is a new initiative, spurred by an earlier OIG report that SNFs often bill for the highest level of therapy even if it is not necessarily required. The OIG found that in 2009, SNFs billed one-quarter of claims in error, resulting in $1.5 billion in inappropriate Medicare payments. This report will describe the policies and practices for billing among SNFs and take into account the changes CMS has made for billing Medicare Part A stays.
  • Questionable billing patterns for Part B services during nursing home stays – For this FY 2014 report, which also appeared on the 2013 Work Plan, the OIG will identify questionable billing patterns associated with nursing homes and Medicare providers for Part B services that are provided and not paid for under Part A. This will include stays where benefits have been exhausted, or stays that are affected by the “3-day prior-in-patient-stay,” which the 2 Midnight Rule tries to clarify. In July 2013, the OIG issued a memorandum report that looked at some of the issues with payment coverage, “Hospitals’ Use of Observation Stays and Short Inpatient Stays for Medicare Beneficiaries
  • State agency verification of deficiency corrections – This initiative is a carry-over from the 2013 list. The OIG plans to check whether State survey agencies are verifying that plans of correction have been implemented for deficiencies found during surveys. A previous report from the OIG found that one SA was not checking facilities to ensure this was done, and the project has not been expanded to include more SAs.
  • Program for national background checks on long-term-care employees – In a report that will be put out in FY 2017, the OIG will be reporting on the procedures that are used by participating States to ensure long term care providers are conducting background checks on prospective employees/providers who would have direct access to patients. This focus area was on the 2013 Work Plan as well, so it is a continuing effort.

In a continued effort by the CMS to reduce fraud and unnecessary payments, all of the initiatives under the Home Health and Other Community-Based Care section focus on billing and payments. These include:

  • Home health services – provider and beneficiary eligibility – Review of HHA claims to State Medicaid programs to determine if appropriate criteria to provide home health services were met by providers and if beneficiaries met the criteria to receive these services.
  • Adult day health services – the OIG will review Medicaid payments to States to determine of providers complied with Federal and State requirements in determining if beneficiaries enrolled met eligibility requirements and services were provided according to the care plan.
  • Continuing day treatment mental health services – This is yet another area where the OIG will be reviewing Medicaid payments to ensure that CDT mental health providers’ claims were adequately supported.

The OIG Work Plan also includes reviewing hospice in assisted living facilities, and two carry-over home health services initiatives, home health prospective payment system requirements and employment of individuals with criminal convictions.



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