The Office of Inspector General (OIG) Work Plan for Fiscal Year (FY) 2015 provides brief descriptions of activities that the OIG plans to initiate or continue in FY 2015. The following key items are addressed in the FY 2015 work plan for Nursing Homes.
Medicare Part A billing by skilled nursing facilities
OIG will describe changes in SNF billing practices from FYs 2011 to 2013. Prior OIG work found that SNFs increasingly billed for the highest level of therapy even though beneficiary characteristics remained largely unchanged. OIG also found that SNFs billed one-quarter of all 2009 claims in error; this erroneous billing resulted in $1.5 billion in inappropriate Medicare payments. CMS has made substantial changes to how SNFs bill for services for Medicare Part A stays.
Questionable billing patterns for Part B services during nursing home stays
OIG will identify questionable billing patterns associated with nursing homes and Medicare providers for Part B services provided to nursing home residents during stays not paid under Part A (for example, stays during which benefits are exhausted or the 3-day prior-inpatient-stay requirement is not met). A series of studies will examine several broad categories of services such as foot care. Congress directed OIG to monitor Part B billing for abuse during non-Part A stays to ensure that no excessive services are provided.
State agency verification of deficiency corrections
OIG will determine whether State survey agencies verified correction plans for deficiencies identified during nursing home recertification surveys. A prior OIG review found that one State survey agency did not always verify that nursing homes corrected deficiencies identified during surveys in accordance with Federal requirements. Federal regulations require nursing homes to submit correction plans to the State survey agency or CMS for deficiencies identified during surveys. CMS requires State survey agencies to verify the correction of identified deficiencies through onsite reviews or by obtaining other evidence of correction.
Program for national background checks for long-term-care employees
OIG will review the procedures implemented by participating States for long-term-care facilities or providers to conduct background checks on prospective employees and providers who would have direct access to patients and determine the costs of conducting background checks. OIG will determine the outcomes of the States’ programs and determine whether the programs led to any unintended consequences. Section 6201 of 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 direct patient access employees of nursing facilities and other long-term-care providers.
Hospitalizations of nursing home residents for manageable and preventable conditions
OIG will determine the extent to which Medicare beneficiaries residing in nursing homes are hospitalized as a result of conditions thought to be manageable or preventable in the nursing home setting. A 2013 OIG review found that 25 percent of Medicare beneficiaries were hospitalized for any reason in FY 2011. OIG reports that Hospitalizations of nursing home residents are costly to Medicare and may indicate quality-of-care problems in nursing homes.