The U.S. Department of Health and Human Services’ Office of the Inspector General (OIG) released its annual Work Plan (Work Plan) for fiscal year 2013 (FY 2013) on Oct. 13, 2012. The Work Plan identifies payment and fraud and abuse issues with respect to various classes of Medicare providers and suppliers. In FY 2013, the OIG intends to focus on the following key areas of program vulnerability relevant to post-acute care providers.
Skilled Nursing Facilities (SNFs)
Adverse Events and Requirements for Quality of Care in SNFs. The OIG will continue to estimate the national incidence of adverse or temporary harm events for Medicare beneficiaries receiving care in SNFs, determine the extent to which such events were preventable and estimate the related costs to Medicare associated with such events. The OIG will also continue to review the extent to which SNFs have used Residential Assessment Instruments (RAIs) to develop and adhere to care plans to better provide services to beneficiaries. Although SNFs participating in Medicare and Medicaid are required to use RAIs, nearly 25 percent of residents did not receive all the services identified in care plans.
State Agency Verification, Deficiency Corrections, Oversight of Poor Performance. The OIG will work to identify poorly performing nursing homes and determine the extent to which CMS and states actually utilize enforcement measures to improve and monitor poor performance. Because a prior OIG review found that certain state survey agencies did not always verify the correction of deficiencies documented in the survey process in accordance with federal law, improvement of the state verification process will be a new area of focus for the OIG.
Home Health Agencies
New Face-to-Face Requirement. The Patient Protection and Affordable Care Act (PPACA) mandated that physicians who certify beneficiaries as eligible for Medicare home health services must have face-to-face encounters with beneficiaries within 120 days. The OIG will begin to determine whether this requirement is being met.
Employment of Home Health Aides with Criminal Convictions. The OIG will begin determining whether HHAs are complying with state requirements that criminal background checks be conducted on home health aides.
Missing or Incorrect Patient Outcome and Assessment Data. The OIG will review Outcome and Assessment Information Set (OASIS) data to identify payments for episodes of care for which OASIS data was not submitted, or for which the billing codes on the claims are inconsistent with OASIS data. OASIS data submission is required as a condition for payment and is used to assess clinical needs, functional status and service utilization of a beneficiary receiving home health services.
Fraud and Abuse Risk Assessment. Because prior investigations have found that the home health benefit may be susceptible to fraud, the OIG will review activities performed by CMS and its contractors to identify and prevent improper payments. The OIG will also review compliance with various aspects of the home health prospective payment system, including the documentation required in support of claims paid by Medicare for home health services.
The OIG’s Office of Evaluation and Inspections (OEI) will review hospices’ marketing materials, practices and their financial relationships with SNFs. The OIG previously found that 82 percent of hospice claims for beneficiaries in SNFs did not meet Medicare coverage requirements. MedPAC has also noted that hospices and SNFs may be involved in inappropriate enrollment and compensation arrangements, and there are instances in which hospices aggressively marketed services to SNF residents. The OIG continues to be concerned that hospices are admitting residents from SNFs who do not meet the benefit coverage requirements due to either pressure from SNFs, the increased potential for profit to the hospice or other inappropriate financial arrangements between providers. Hospice providers should ensure they are admitting patients who meet the hospice benefit criteria, should review marketing materials to ensure that they adequately describe the benefit and eligibility criteria, and should make clear that hospice care means foregoing curative treatment.
Inpatient Rehabilitation Facilities (IRFs)
The OIG will continue to determine, through use of CMS’ National Assessment Collection Database (NACD) — which is used to gather data to determine payment for each Medicare patient admitted to an IRF — whether IRFs received reduced payments for claims that were transmitted to the NACD more than 27 days after a beneficiary’s discharge. The payment rate for overdue submissions should be reduced by 25 percent according to federal regulations; however, CMS has historically had difficulty tracking delinquent submission data. The OIG will also begin examining the appropriateness of admissions to IRFs and the level of group therapy provided in IRFs.
Long-Term Care Hospitals (LTCHs)
The OIG will determine the extent to which Medicare made improper payments for interrupted stays in LTCH in 2011. The OIG will also identify readmission patterns and determine the extent to which LTCHs readmit patients directly following the interrupted stay periods. An interrupted stay occurs when a patient is discharged from an LTCH for treatment and services that are not available at the LTCH and is then readmitted after a specific number of days. Interrupted stays in LTCHs cause an adjustment in Medicare payments. Prior OIG work has identified vulnerabilities in CMS’s ability to detect readmissions and appropriately pay for interrupted stays