​The U.S. Department of Health & Human Services 2012 Office of Inspector General (OIG) Work Plan offers providers a helpful overview of Medicare enforcement priorities. With respect to skilled nursing facilities (SNFs), the work plan contains five “carryovers” from 2011 and three new areas of inquiry.
The plan is a helpful guide of priority areas in need of improvement and those coming under imminent scrutiny. In general, the common theme is monitoring quality of care while simultaneously cracking down on fraud and abuse.

Carryover Items

Following are summaries of the most important items that OIG has carried over from its 2011 Work Plan:
  • Medicare requirements for quality of care in SNFs. OIG will review how SNFs have addressed federal requirements related to quality of care, with a focus on the extent to which SNFs have developed plans of care based on assessments of beneficiaries, provided services to beneficiaries in accordance with the plans of care, and planned for beneficiaries’ discharges. The review will also cover SNFs’ use of resident assessment instruments to develop nursing home residents’ plans of care. It is essential for facilities to ensure their compliance related to these areas.
  • Oversight of poorly performing nursing homes. OIG will review the Centers for Medicare & Medicaid Services’ (CMS’) and states’ use of enforcement measures and their impact on improving the quality of care beneficiaries received in “poorly performing” nursing homes. The review will also determine the extent to which CMS and states follow up to ensure that poorly performing nursing homes implement correction plans. Facilities with a history of poor performance should take note that persistent underperformance is not going to be tolerated to the same extent it may have been in the past.
  • Nursing home emergency preparedness and evacuations during selected natural disasters. OIG will review nursing homes’ emergency plans and emergency preparedness deficiencies cited by state surveyors to determine the sufficiency of the nursing homes’ plans and their implementation of the plans. The review will highlight the experiences of selected nursing homes, including challenges, successes, and lessons learned when they implemented their plans during recent disasters, such as hurricanes, floods, and wildfires. It is critical for staff to be trained in facility disaster and emergency procedures.
  • Medicare Part A payments to SNFs. OIG will review the extent to which payments to SNFs meet Medicare coverage requirements by conducting a medical review to determine whether claims were medically necessary, sufficiently documented, and coded correctly during 2009. In a prior report, OIG found that 26 percent of claims had resource utilization groups (RUGs) that were not supported by patients’ medical records. According to OIG, it represented $542 million in potential overpayments for that year. Consequently, Medicare regulators suspect that some facilities are accepting patients for Part A stays that do not qualify under the RUGs in which they are placed.
  • Hospitalizations and rehospitalizations of nursing facility residents. OIG will review the extent to which Medicare beneficiaries residing in nursing homes have been hospitalized and rehospitalized. The review will assess CMS oversight of nursing homes with residents that have high rates of hospitalization.

New Work Plan Items

The following three areas are new to the OIG’s Work Plan for nursing homes. Undoubtedly, the Affordable Care Act and the new culture of accountability in health care are shaping these new areas of scrutiny.
  • Nursing home compliance plans. OIG will review Medicare and Medicaid certified nursing facilities’ implementation of compliance plans as part of their day-to-day operations and whether the plans contain elements identified in OIG’s compliance program guidance. The review will also assess whether CMS has incorporated compliance requirements into the agency’s participation requirements.
  • Section 6102 of the Affordable Care Act (ACA) requires nursing homes to operate a compliance and ethics program, containing at least eight components, to prevent and detect criminal, civil, and administrative violations and promote quality of care. The ACA requires CMS to issue regulations in 2012 and calls for SNFs to have already established plans that meet such requirements on or after 2013.
  • Safety and quality of post-acute care for Medicare beneficiaries. OIG will review the quality of care and safety of Medicare beneficiaries transferred from acute-care hospitals to post-acute care. They will evaluate the transfer process and also identify rates of adverse events and preventable hospital readmissions from post-acute care settings. Primarily, OIG will focus on these three post-acute settings: SNFs, intermediate rehabilitation facilities, and long term care hospitals.
  • Questionable billing patterns during non-Part A 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 whose stays are not paid for under Medicare’s Part A SNF benefit. Part B services provided during a non-Part A stay must be billed directly by suppliers and other providers. Congress specifically directed OIG to monitor these services for abuse.

SNFs Must Be Proactive

While skilled nursing facilities should certainly not limit their compliance efforts to OIG work plan items alone, they should take note of the new and carryover topics in refining and expanding those efforts. By self-auditing on these issues, facilities can take proactive and preventive steps to prevent regulatory problems before they result in government action.
Check out Provider’s May 2012 print issue for a deeper look at the OIG’s efforts, in conjunction with HHS, in the pursuit of fraud and abuse by nursing home providers. Specifically, the cover story will examine how some contractors are taking a vigorous approach to auditing providiers.
Elliot Zemel is an associate at Fenton Nelson, a law firm that advises health care facilities on regulatory compliance requirements. He can be reached at ezemel@fentonnelson.com