OIG’s 2012 Work Plan For Nursing Facilities: Same Fraud, Different Enforcement

Recently, the United States Department of Health and Human Services Office of Inspector General (“OIG”) published its Work Plan for fiscal year 2012 (“Work Plan”) and delineated focus points for nursing facilities and new enforcement in 2012. The Work Plan is not much different than previous work plans with the exception of increased areas of enforcement, as well as a few new areas to be looked at by OIG.

For nursing homes, below are the subheadings that show OIG’s focus in its Work Plan:

  • Medicare Requirements for Quality of Care in Skilled Nursing Facilities
  • Safety and Quality of Post-Acute Care for Medicare Beneficiaries (New)
  • Nursing Home Compliance Plans (New)
  • Oversight of Poorly Performing Nursing Homes
  • Nursing Home Emergency Preparedness and Evacuations During Selected Natural Disasters
  • Medicare Part A Payments to Skilled Nursing Facilities
  • Hospitalizations and Rehospitalizations of Nursing Home Residents
  • Questionable Billing Patterns During Non-Part A Nursing Home Stays (New)

Most of these are issues nursing facilities are familiar with, but a few new ones include the safety and quality of post-acute care, with the OIG focusing on the transfer process from hospitals to nursing homes. OIG notes that hospital stays have fallen steadily, resulting in increased transfers to nursing homes, perhaps too early, which may affect the safety of Medicare beneficiaries in the transfer transition. Second, OIG is focusing on nursing home compliance plans, and notes the Affordable Care Act requirements for CMS to issue regulations in 2012 with nursing facilities to have plans that meet such requirements on or after 2013. Nursing homes can better prepare themselves by updating or making sure they have effective compliance programs in their facilities. Finally, the Centers for Medicare and Medicaid Services (“CMS”) will focus on Part B services provided during a non-Part A stay which must be billed directly by suppliers and other providers.

Despite the new areas of focus OIG will be concerned with in the Work Plan for 2012, some of the same elements of OIG’s focus remain. In particular, OIG is focused on quality of care in skilled nursing facilities and focuses in its Work Plan on nursing facilities’ plans of care, providing services in accordance with plans of care, and that facilities update their plans of care to include services identified in Resident Assessment Instruments (“RAIs”). OIG has discovered that not all residents’ needs were addressed through plans of care as raised in resident RAIs. OIG also noted that some nursing home residents did not receive all psychosocial services identified in the care plans.

As part of its focus on quality of care, OIG also intends to review the extent to which the residents in nursing homes have been hospitalized and rehospitalized. OIG believes that these hospitalizations of nursing home residents are costly, and intends to oversee CMS’ oversight of nursing homes who residents have high rates of hospitalization.

In all, although there are certain new elements to OIG’s focus in the nursing home industry, many of the same core elements remain: quality of care and addressing the needs of residents in the nursing home setting. As a backdrop, OIG intends to be more aggressive in its suggestion that nursing homes should obtain effective compliance plans to be ready for the Affordable Care Act’s requirements in 2013.

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The opinions expressed on this blog are those of the author and are not to be construed as legal advice.

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