OIG Work Plan 2014 – Nursing Homes

OIG Work Plan 2014 - Nursing Homes

After a nearly four month delay, the OIG work plan 2014 was finally released. For nursing home operators, there’s a bit of good news and bad news in the work plan. The good news? Of the five nursing home related initiatives outlined in the work plan, four are “works in progress” or in other words, projects that were started in prior years and thus, should be familiar to providers. The bad news? (Doesn’t there always seem to be bad news to temper the good?) The “new” OIG focus area concentrates on “Medicare Part A billing by skilled nursing facilities” which probably includes just about everyone who is reading this blog.

For those new readers out there, you might be saying “ok, so the OIG work plan 2014 was released, is it that big of a deal?” Here are just a few quick points:

  • For FY 2013, the OIG expects recoveries of $5.8 BILLION (that’s a whole lot of zeros)
  • The OIG estimates savings of $19.4 BILLION (more zeros) for FY 2013 based on recommendations they have made
  • In FY 2013, the OIG reports 3,214 exclusions from federal health care programs, 960 criminal actions due to crimes against HHS programs and 472 civil actions which include false claims and civil monetary penalties among other things

The bottom line here is that the OIG work plan 2014 for nursing homes represents an ongoing effort by the OIG to curb alleged improper activity by providers. Judging by the results in FY 2013 alone, it doesn’t seem very likely that the OIG is going to curb its enforcement activities, so those providers who haven’t taken notice or are new to the industry-it’s time to pay attention.

What’s in the OIG work plan 2014 for nursing homes?

As I mentioned earlier, there are five focus areas outlined in the work plan. Let’s first cover the four which are projects (as the OIG likes to call them) which were initiated in prior years:

  • Questionable billing patterns for part B services during nursing home stay-this one originates from a directive from Congress, requesting that the OIG investigate potential abuse of part B billing.
  • State agency verification of deficiency corrections-as a part of an OIG review, it was discovered that a state agency did not follow up to ensure that a provider addressed and corrected identified deficiencies.
  • Program for national background checks for long term care employees-the OIG will review the procedures and cost of background checks conducted by States on long term care employees and providers.
  • Hospitalizations of nursing home residents for manageable and preventable conditions-a 2013 OIG review found that 25% of Medicare patients in a nursing home were hospitalized. Such hospitalizations are costly and the OIG is concerned that it is indicative of quality of care issues.

There’s a new initiative in the OIG work plan 2014 for nursing homes

I mentioned that there were five nursing home projects in the OIG work plan 2014 and we’ve covered four of them, which are carry overs from past years. However, there is a new and potentially significant one this year…Medicare Part A billing by skilled nursing facilities. A little background here-the OIG took a look at claims for 2011 and found that 25% of all claims resulted in $1.5 billion in “inappropriate Medicare payments”. In addition, the OIG has found that even though Medicare beneficiary characteristics remained unchanged, SNF providers increasingly billed at the highest level of therapy. Is it any wonder that the OIG intends on focusing in on “variation in billing among SNFs”?

ALF’s in the OIG work plan 2014? Huh?

Yep-for those long term care providers out there that have both a SNF and ALF, this will be of particular interest to you. There is a new initiative in the OIG work plan 2014 that calls for the review of hospices which provide services to Medicare beneficiaries in assisted living facilities. The trigger here is the fact that ALF residents receiving hospice services experience the longest lengths of stay. The OIG will look at hospice patients’ lengths of stay and care received while in an ALF setting.

Compliance program, compliance program, compliance program

In real estate, the mantra is location, location, location. For long term care providers out there, after reading about the OIG work plan 2014 for nursing homes, the mantra should be compliance program, compliance program, compliance program. It’s been my experience that the vast majority of providers do the right thing but regrettably, our industry has its fair share of bad apples. And it’s these bad apples that hit the headlines and get the attention of the public and the OIG.

So now that you’ve seen the highlights of this year’s OIG work plan and know where the OIG will be spending their time this coming year, it’s time to go out and be proactive. (If you’d like to read the full text, I’ll encourage you to download a copy of the OIG Work Plan 2014.) A dynamic and active compliance program can be an effective tool in your fight to stay out of the headlines and out of the sights of the OIG.

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.

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