To protect the integrity of HHS programs and operations along with the well-being of their beneficiaries, the OIG and other HHS agencies, including the Department of Justice (DOJ), collaborate to execute a Work Plan each calendar year. The undertakings that OIG has determined to be focus areas to reduce fraud, waste, and abuse.
Based upon the fiscal year (FY) 2013 results, the HHS OIG Work Plan is expected to recover over $5.8 billion, including approximately $850 million in audit receivables and almost $5 billion in investigative results. In the same period, 3,214 individuals and entities became excluded from participation in Federal healthcare programs. Individuals and entities participating in crimes against HHS programs resulted in 960 criminal actions. In addition, there were 472 civil matters, including false claims and unjust-enrichment lawsuits, settlements, and administrative repayments.
The 2014 Work Plan key focus areas for nursing homes include the following: fighting fraud, waste and abuse and promoting quality, safety and value. Each project contains primary objectives for review of specific HHS programs and how to measure the outcomes. Compliagent offers audits and services that assist SNFs in identifying potential risk in these focus areas.
Medicare Part A Billing by Skilled Nursing Facilities (New)
This is new focus area consists of reviewing SNF billing practices in comparison to any variation among other SNFs. In 2009 SNFs were found to have billed one-quarter of Medicare claims in error, totaling $1.5 billion in inappropriate payments.
- Our solution - Medicare Eligibility Audit is a focused review of a selected resident sample to determine whether residents were appropriate for skilled coverage.
Questionable Billing Pattern For Part B Services During Nursing Home Stays
The OIG continues to target Medicare Part B billing patterns for abuse of ancillary services (e.g. podiatry services) provided to non-Medicare Part A residents.
- Our solution - Medicare Part B Billing Audit is a focused review of selected resident sample to determine whether consolidated billing notices were utilized to prevent inappropriate billing by ancillary services and the medical necessity of the referral to such ancillary services.
State Agency Verification of Deficiency Corrections
The OIG continues to review State survey agencies to ensure verification and implementation of plan of corrections (POC) for deficiencies identified during SNF recertification surveys. The Centers for Medicare & Medicaid Services (CMS) requires State survey agencies to confirm the submitted correction plans by conducting an onsite review or obtaining proper documents as proof of compliance with the regulations.
- Our solution - Review of Past Performance Audit provides analysis of deficiency trends over a five year period and an assessment of the effectiveness of previously submitted POCS.
- Our solution - Mock Survey Audit Tools can be utilized to very that submitted POCs have been implemented and are effective.
Program For National Background Checks for Long-Term Care Employees
OIG is evaluating States' guidelines imposed on SNFs to conduct background checks on future employees and providers who would interact directly with residents.
- Our solution - Mock Survey Audit Tools can be utilized to review a sample of employee files to ensure that background screenings are conducted prior to the date of hire.
- Our solution - in addition to background check, Compliagent facilitates monthly exclusion screening for employees.
Hospitalizations of Nursing Home Residents For Manageable And Preventable Conditions
OIG continues to examine unnecessary hospitalization from SNFs of Medicare beneficiaries. Twenty-five percent of Medicare beneficiaries were discharged to hospitals in 2011 according to the 2013 OIG review. Not only are hospitalizations of SNF residents costly to the Medicare program, but also pose potential quality-of-care issues in SNFs.
- Our solution - Preventable Hospital Re-Admission Audit analyzes resident re-hospitalizations and evaluates the facility's ability to reduce unnecessary and preventable discharges to the hospital.