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Tammy Brunetti, CPA

Are you a Medicare or Medicaid Provider? The OIG 2017 Work Plan has been released, and here’s what you need to know

2016-11-17

Medicare

The OIG will be reviewing:

  • Oversight of SNFs’ compliance with patient admission requirements
  • A number of policies on hospice care, including oversight of certification surveys worker licensure requirements
  • Evaluation of CMS’ Fraud Prevention System

The Work Plan addresses Medicare Part A and Part B program management issues like delivery system reform, including Medicare shared savings programs, ACOs, use of electronic health records, and implementation of a Quality Payment Program.

Medicaid

The OIG will be reviewing payments for Home and Community Based Services (HCBS) Waiver Programs to determine if payments are covering room and board costs, as these are not allowed to be paid with federal funds.

States may use various methods to pay for such services, such as a settlement process that is based on annual cost reports or prospective rates with rate adjustments that are based on cost report data and cost-trending factors. The OIG will determine whether selected states claimed federal reimbursement for room and board costs associated with services provided under the terms and conditions of HCBS waiver programs, and whether HCBS payments included the costs of room and board and identify the methods the states used to determine the amounts paid.

Third-party liability payment collections have become a hot topic recently, especially as they relate to Disproportionate Share Hospital payments. What was decided is that the OIG will now determine if states have taken action to ensure that Medicaid is the payer of last resort. They will do this by identifying whether a third-party payer exists and if the state has correctly reported the third-party liability to CMS.

Here is a summary of the major initiatives identified in the 2017 Work Plan by entity type:

Nursing Homes:

  • Complaint investigation data brief: all nursing home complaints categorized as immediate jeopardy and actual harm must be investigated within a 2- and 10-day timeframe, respectively
  • Unreported incidents of potential abuse and neglect: determine whether these incidents were properly reported and investigated in accordance with applicable federal and state requirements, and whether each reportable incident was investigated and subsequently prosecuted by the state, if appropriate
  • Skilled nursing facility (SNF) reimbursement: the OIG will review the documentation at selected SNFs to determine if it meets the requirements for each particular resource utilization group. This area gets a lot of attention, as previous OIG work found that SNFs are billing for higher levels of therapy than were provided or were reasonable or necessary
  • Potentially avoidable hospitalizations of Medicare- and Medicaid-eligible SNF residents: according to the OIG, high occurrences of patient transfers to hospitals for potentially preventable conditions is indicative of poor quality of care. The OIG will review nursing homes with high rates of patient transfers to hospitals for potentially preventable conditions and determine whether the nursing homes provided services to residents in accordance with their care plans.

Hospitals:

  • Incorrect medical assistance days claimed by hospitals: the OIG will determine whether, with respect to Medicaid patient days, Medicare administrative contractors properly settled
  • Medicare cost reports for Medicare disproportionate share hospital (DSH) payments are in accordance with Federal requirements
  • Inpatient psychiatric facility outlier payments: the OIG will evaluate the extent of potential Medicare savings if hospital outpatient stays were ineligible for an outlier payment

Hospice: 

  • Benefit vulnerabilities and recommendations for improvement: the OIG plans to summarize evaluations, audits, and investigative work on Medicare hospices and highlight key recommendations for protecting beneficiaries and improving the program
  • Review of hospices compliance with Medicare requirements: the OIG will review hospice medical records and billing documentation to determine whether Medicare payments for hospice services were made in accordance with Medicare requirements
  • Frequency of nurse on-site visits to assess quality of care and services: Medicare requires that a registered nurse make an on-site visit to the patient's home at least once every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary team meet the patient’s needs. The OIG will determine whether registered nurses made required on-site visits to the homes of Medicare beneficiaries who were in hospice care.

Home Care:

  • Comparing HHA survey documents to Medicare claims data: the OIG will determine whether HHAs are accurately providing patient information to State agencies for recertification surveys.

How can we help?

We can assist in the evaluation of your internal controls and compliance initiatives based on our knowledge and extensive experience in the industry. Contact Tammy Brunetti or any of our healthcare industry specialists with questions.

For more information, view a complete copy of OIG's 2017 Work Plan on their website.