OIG Work Plan Series Installment Two - Long Term Care - Nursing Homes, Hospice, and Home Health

In early November 2015, the Department of Health & Human Services’ Office of Inspector General (OIG) released its 2016 Work Plan, which includes projects specific to certain provider types. This alert will focus on the projects specific to nursing homes, hospice providers, and home health agencies. Overall, there are fewer projects across these three provider types this year than in 2015, and only one is entirely new for 2016.

Nursing Homes

There are two projects focused on nursing homes for 2016; one is new, and one is a continuation of a 2015 project.

New for 2016 is a project focused on skilled nursing facility (SNF) prospective payment system requirements. OIG will review for compliance with these requirements, with an emphasis on whether SNFs are completing and maintaining appropriate documentation to support claims paid by Medicare. OIG will also look for compliance with the documentation requirements specified in 42 C.F.R. § 483.20 in support of the reasonableness and necessity of the care provided by the SNF (e.g., a physician order for care at the time of admission, a comprehensive assessment, and a comprehensive plan of care).

Continued from 2015 is a project focused on the National Background Check Program for long-term-care employees, a program implemented pursuant to section 6201 of the Patient Protection and Affordable Care Act. This program requires national and state background checks for prospective employees of nursing homes and other long-term-care providers, and OIG will report the status and results to date from the program’s first four years.


The only project specifically focused on hospice providers for 2016, “Hospice general inpatient care,” is a revised version of the same project that was in place for 2015. As in 2015, OIG will continue to focus on whether the general inpatient care level of the Medicare hospice benefit is being used appropriately.

Notably new for 2016, however, are three updates to this project:

OIG has specified that its focus in reviewing patient medical records will be to address concerns regarding the medical necessity of this level of hospice care, clarifying the more general 2015 statement of concern that the level of care was being “misused.
New for 2016, OIG will focus on reviewing patients’ plans of care for compliance with “key requirements” (though OIG does not elaborate on which requirements it considers to be “key”).
Also new for 2016 is a specific focus on determining whether payments made by Medicare for hospice services were in accordance with Medicare requirements.

Home Health

Notably, there are no new projects for home health providers for 2016. Instead, the projects for 2016 are continuations of previous projects and have a consistent emphasis on the appropriateness of payments. As before, OIG will continue to focus on home health prospective payment system requirements in the Medicare program, with particular attention to whether providers are maintaining appropriate documentation to support payments made by Medicare and otherwise complying with federal laws and regulations. In the Medicaid program, OIG will focus on state payments for adult day care services to assess whether providers were in compliance with federal and state requirements.

To review the entire document and formatting for this alert (e.g., footnotes), please access the original below:

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