2015 OIG Work Plan – Nursing Homes


With the calendar ready to turn to November, the feds released the 2015 OIG Work Plan on October 31, 2014.  Traditionally, the OIG has attempted to release its work plan in October, so it shouldn’t have come as a complete surprise that they made the 2015 OIG work plan a Halloween treat of sorts. This year’s work plan weighs in with a more “petite” 90 pages as opposed to the more hefty 101 pages last year.  For those of you who would like to get a brief summary of the work plan, please check out our 2015 OIG Work Plan Overview. If you’re new to the OIG work plan or would enjoy plowing through the entire 90 page, please download your full copy of the OIG 2015 work plan.

2015 OIG Work Plan – Nursing Homes, what’s in it?

When it comes to nursing home providers, the 2015 OIG work plan includes five projects relative to long term care. The good news here is none of the projects (that’s what the OIG likes to call their investigative and enforcement activities) are new this year. In other words, all of the projects were initiated in prior years and the OIG has decided to carry them forward in FY 2015. And without further ado (a little drum roll please), here they are:

Medicare Part A billing by skilled nursing facilities
The OIG alleges that based on prior audit and investigation, they found that SNF providers increasingly billed at the highest level of therapy even though the clinical characteristics of the patient remained largely unchanged. To further emphasize their point, the OIG indicates that one quarter of all 2009 SNF claims were billed erroneously and this resulted in $1.5 BILLION in “inappropriate” Medicare payments. (That’s a whole lot of erroneous billing!)

What should providers do? Well, for starters, now is a great time to do an annual review of your compliance program. (If you don’t have one, it’s time to start. Learn more about compliance programs.) Specifically, make sure that you’re taking a sampling of your Medicare billing and conducting a thorough audit on those claims with special attention to those claims that involve rehabilitative services. If your audits reveal issues with the claims make sure that you take immediate and appropriate action to address the issues. (And document those actions!)

Questionable billing patterns for part B services during nursing home stays
In prior years, Congress has directed the OIG to monitor part B billing for non-part A stays to insure that there are no questionable billing patterns resulting from excessive services.

What should providers do? Insure that your compliance audits sample part B claims that occur during part A stays. As a part of that audit, be mindful to assess the appropriateness of the services.

State agency verification of deficiency corrections
In a prior review, the OIG identified that a state agency did not always verify that the nursing home providers corrected their deficiencies which is a federal requirement. Consequently, the OIG will determine whether state agencies do this verification via either an onsite visit or by obtaining other evidence of correction.

What should providers do? Hopefully, you don’t have a lengthy 2567 to deal with and consequently, your POC is not very long. Regardless, part of your quality assurance system should be to insure that the components of your POC are successfully implemented.

Program for national background checks for long term care employees
The Patient Protection and Affordable Care Act required the Secretary of Health and Human Services to implement a program for States to conduct national and State background checks for prospective direct patient access employees of nursing facilities and other long term care providers. The OIG intends on reviewing these state procedures to determine costs, outcomes and any unintended consequences.

What should providers do? Check with your state agency and verify that you are following their procedures for background checks for your applicable employees. Your quality assurance program should include a review of your adherence to those procedures.

Hospitalizations of nursing home residents for manageable and preventable conditions
A 2013 OIG review found that 25% of Medicare beneficiaries were hospitalized. Such hospitalizations are costly to Medicare and may potentially indicate quality of care issues in nursing homes. As such, the OIG will look to determine if hospitalizations of nursing home residents were as a result of conditions thought to be manageable or preventable in the nursing home setting.

What should providers do? As a part of your quality assurance process, a review of your patient hospitalizations are in order. With the amount of attention being paid to re-hospitalization rates, it makes sense to monitor these occurrences.

The 2015 OIG Work Plan includes assisted living – what the…?

Yep, that’s right. For those providers out there that have assisted living facilities, the OIG has thrown assisted living facilities into the OIG 2015 work plan. As was the case last year, they will be examining hospice care administered to ALF residents. The OIG intends on determining length of stays, levels of care received and common terminal illnesses of beneficiaries who receive hospice care in an ALF setting. Of course, this does not directly affect ALF providers but rather hospice care and the potential for reforming the hospice payment system.

Final thoughts on the 2015 OIG Work Plan

So there you have it. That wasn’t so bad was it? Those providers who read my blog for the OIG 2014 work plan (and did something about it) you’re probably saying no big deal. If that’s you, congrats and sleep well tonight. If reading this gives you a case of insomnia, time to get cracking.  A good ounce of an effective compliance program is worth a pound of OIG’s “cure”!

When you need proven expertise and performance

Craig Fukushima, NHA, MBA

Mr. Craig T. Fukushima’s health care experience spans more than 35 years with special expertise in the long term care sector, including implementation of innovative health care projects in domestic and international locations.