The HHS Office of Inspector General (OIG) has published its annual Work Plan for Fiscal Year 2016.  The Work Plan  summarizes new and ongoing reviews and activities that OIG plans to pursue with respect to federal health care programs, including Medicare and Medicaid, during the current fiscal year and beyond.  Work Plan agenda items for Nursing Homes, Home Health and Hospice are summarized below. 

Nursing Homes

National background check program for long-term care employees

OIG will report on the implementation status and early results for the National Background Check Program for long-term-care employees from the first 4 years of the program. The Patient Protection and Affordable Care Act (ACA) requires the Secretary of Health and Human Services to carry out a nationwide program for states to conduct national and state background checks for prospective employees of nursing facilities and other long-term care providers. The program is administered by CMS. To carry out the nationwide program, CMS has issued solicitations for grant awards. All states, the District of Columbia, and U.S. territories are eligible to be considered for a grant award.

Skilled nursing facility prospective payment system requirements

OIG will review compliance with various aspects of the skilled nursing facility (SNF) prospective payment system, including the documentation requirement in support of the claims paid by Medicare. Prior OIG reviews have found that Medicare payments for therapy greatly exceeded SNFs’ costs for therapy. In addition, OIG has found that SNFs have increasingly billed for the highest level of therapy even though key beneficiary characteristics remained largely the same. OIG will determine whether SNF claims were paid in accordance with Federal laws and regulations. All documentation requirements specified in 42 CFR § 483.20 must be met to ensure that SNF care is reasonable and necessary. Such SNF documentation includes (1) a physician order at the time of admission for the resident’s immediate care; (2) a comprehensive assessment; and (3) a comprehensive plan of care prepared by an interdisciplinary team that includes the attending physician, a registered nurse, and other appropriate staff. Prior OIG audits, investigations, and inspections have identified areas at risk for noncompliance with SNF Medicare billing requirements. This a new Work Plan activity.

Home Health

Home health prospective payment system requirements

OIG will review compliance with various aspects of the home health prospective payment system (PPS), including the documentation required in support of the claims paid by Medicare. OIG will determine whether home health claims were paid in accordance with Federal laws and regulations. A prior OIG report found that one in four home health agencies (HHAs) had questionable billing. Further, CMS designated newly enrolling HHAs as high-risk providers, citing their record of fraud, waste, and abuse. OIG says that since 2010, nearly $1 billion in improper Medicare payments and fraud has been identified relating to the home health benefit. This is an ongoing OIG review activity.

Hospice

Hospice general inpatient care

OIG will review the use of the general inpatient care level of the Medicare hospice benefit, assessing the appropriateness of hospices’ general inpatient care claims and the content of election statements for hospice beneficiaries who receive general inpatient care. OIG will also review hospice medical records to address concerns that this level of hospice care is being billed when that level of service is not medically necessary. OIG will review beneficiaries’ plans of care and determine whether they meet key requirements, e.g., the care is palliative rather than curative and the hospice agency assumes the responsibility for medical care related to the beneficiary’s terminal illness and related conditions.  In addition, OIG will determine whether Medicare payments for hospice services were made in accordance with Medicare requirements.

Providers are well-advised to keep OIG Work Plan initiatives in mind for day-to-day operations and in implementing their compliance programs. The OIG Work Plan provides guidance on compliance risk areas likely to be targeted in government audits and investigations.  Advance attention to these areas can help to ensure that all Medicare and Medicaid requirements are met.