In early November, the Office of Inspector General (OIG) released its 2017 Fiscal Year Work Plan, which summarizes new and ongoing reviews and activities that OIG plans to pursue with respect to Health and Human Services (HHS) programs and operations. New areas of focus for skilled nursing facilities (SNFs), hospices, and home health agencies (HHAs) reflect OIG’s continued efforts to identify and offer recommendations to reduce improper payments, prevent and deter fraud, and encourage economical payment policies.
- Nursing Home Complaint Investigations: OIG will determine whether state agencies are timely investigating serious nursing home complaints, such as those categorized as immediate jeopardy and actual harm, which must be investigated within a 2- and 10-day timeframe, respectively.
- Reporting Incidents of Potential Abuse and Neglect: This area of focus will assess the incidence of abuse and neglect of Medicare beneficiaries to determine whether these incidences were properly reported and investigated in accordance with applicable federal and state requirements. Additionally, OIG will interview state officials to determine whether they have appropriately prosecuted reportable incidents.
- Reimbursement: SNFs are required to regularly assess their patients using a tool called the Minimum Data Set, which helps to classify each patient into a resource utilization group for payment. Previous OIG reports have asserted that SNFs are billing for higher levels of therapy than were provided or were reasonable or necessary. The plan will focus on reviewing selected SNF documentation to determine whether requirements are met for each particular resource utilization group.
- Adverse Event Screening Tool: OIG developed this tool as a part of a study released in February 2014 and will seek to disseminate practical information about this tool for use by those in the industry.
- Review of Program Vulnerabilities and Recommendations for Improvement: OIG will summarize its evaluations, audits, and investigative work on Medicare hospices, and make recommendations for improvements to the program in response to identified vulnerabilities in payment, compliance, oversight, and quality-of-care concerns.
- Review of Compliance with Medicare Requirements: OIG will review hospice medical records and billing documentation to determine whether Medicare payments for services were made in accordance with Medicare conditions and limitations.
- Hospice Home Care – Frequency of Nurse On-Site Visits to Assess Quality of Care and Services: OIG will focus on the Medicare requirement that a registered nurse make an on-site visit to a hospice patient’s home at least once every 14 days to assess the quality of care and services provided and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs.
Home Health Services:
- Comparison of Survey Documents to Claims Data: Previous OIG work has concluded that home health programs are prone to fraud waste and abuse; therefore, OIG will focus on whether home health agencies are accurately reporting patient information to state agencies for recertification surveys.
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