Download presentation
Presentation is loading. Please wait.
Published byJeffrey Moody Modified over 7 years ago
1
LeadingAge Legal Update: Nursing Home Compliance Office of the Inspector General October 21, 2014 Carrie S. Gilbert Dressman Benzinger LaVelle psc cgilbert@dbllaw.com 859-341-1881
2
Enforcement Authority Detecting and preventing fraud, waste and abuse in HHS programs Majority of resources focused on Medicare & Medicaid Exclusion authority Civil Monetary Penalties
3
2014 OIG Publications 2014 Work Plan Civil Monetary Penalties – Proposed Rule Report on Compliance with Reporting Obligations – Abuse & Neglect Report on Adverse Events in SNFs Compendium of Priorities
4
2014 Work Plan – Nursing Facilities January 2014 Outlines OIG’s current focus areas and primary objectives of each project Provider insight into OIG process and what issues OIG will be looking for
5
OIG Work Plan – Nursing Facilities Two primary areas of focus Billing and Payments Questionable billing patterns for Part A and Part B nursing home stays Quality & safety State agency verification of compliance with correction plans National background checks for LTC employees Preventable hospitalizations
6
2014 Work Plan – Billing & Payment Examine variation in Part A billing Increased billing for highest level of therapy, but resident characteristics are unchanged ¼ of SNF’s billings were in error Identify questionable billing patterns related to billing for Medicare Part B services provided during nursing home stays not paid under Part A Congress directed OIG to monitor Part B billing
7
2014 Work Plan – Quality & Safety Review whether state agencies are verifying that NF are implementing correction plans OIG found that at least one State survey agency was not ensuring NF implementation of correction plans and correction of deficiencies Monitor the effectiveness of national background checks for long-term care employees Cost-effectiveness Unintended consequences Hospitalization for preventable and manageable conditions acquired in nursing homes Monitor unnecessary hospitalizations and quality of care
8
Civil Monetary Penalty Proposed Rule OIG recently issued a proposal to amend CMP rules and add rules contained in Affordable Care Act Current CMP Rule permits OIG to levy CMPs on providers that engage in prohibited conduct
9
Additional grounds for penalties Failure to timely grant access to records Ordering or prescribing while excluded – $10,000/violation & 3x amount for each item or service wrongfully claimed Failure to report or return overpayments - $10,000/day False statements in enrollment applications
10
Liability for excluded persons Separately billable items and services Penalties and assessments based on number and value of each separately billable item and service Non-separately billable items and services Penalties based on number of days the provider employed or contracted with the excluded person Assessments based on total costs to employer for employing or contracting with excluded person
11
Aggravating Factors “If any single aggravating circumstance is present, the maximum penalty may be justified.” New aggravating factor – “a person’s level of intent to commit the violation that is greater than minimum intent required to establish liability.” Provide aggravation threshold of $15,000
12
Mitigating Factors Appropriate and timely corrective action – self- report to OIG self-disclosure protocol Raise mitigation threshold from $1,000 to $5,000
13
Additional clarity Provide additional detail on factors OIG considers in determining amount of penalty or length of exclusion Nature and circumstances of violation Degree of culpability of person History of prior offenses Other wrongful conduct Other matters as justice may require Provide OIG with more flexibility in considering such factors
14
Adverse Event Report February 2014 22% of Medicare beneficiaries experience an adverse event 11% of Medicare beneficiaries experience temporary harm events Recommend that AHRQ and CMS focus on nursing home safety and preventing resident harm, including creating list of reportable events and providing guidance to facilities on patient safety
15
Abuse & Neglect Report August 2014 Report found fairly high prevalence of compliance with Federal regulations 95% of nursing facilities had policies reflecting requirement to report incidences of abuse and neglect 76% of nursing facilities had policies reflecting requirement to report incidences of abuse and neglect and subsequent investigation results Recommended that CMS reissue guidance related to abuse and neglect obligations
16
Compendium of Priorities March 2014 Identifies previous recommendations to Congress for which corrective actions have not been completed or OIG believes more could be done by CMS CMS does not necessarily agree with or implement the recommendations Five recommendation areas for nursing facilities
17
Compendium of Priorities Hospice care in nursing homes: Monitor hospices that depend heavily on nursing facility residents Modify the payment system for hospice care in nursing facilities Harm to patients: CMS should Include potential events and information about resident harm in its quality guidance to nursing homes and instruct nursing home surveyors to review facility practices for identifying and reducing adverse events. AHRQ and CMS should collaborate to create and promote a list of potential nursing home events and encourage nursing homes to report adverse events to Patient Safety Organizations.
18
Compendium of Priorities Skilled Nursing Facilities Billing: Increase and expand reviews of SNF claims Monitor compliance with the new therapy assessments Change the current method for determining how much therapy is needed to ensure appropriate payments Improve the accuracy of data items submitted by SNFs Follow up on SNFs that billed in error Monitor overall Medicare payments to SNFs and adjust rates as necessary, Strengthen monitoring of SNFs that disproportionately bill for higher paying resource utilization groups (RUGs), and Follow up on the SNFs identified as having questionable billing practices.
19
Compendium of Priorities Care Planning & Discharge Planning: Strengthen regulations on care planning and discharge planning Provide guidance to SNFs to improve care planning and discharge planning Increase surveyor efforts to identify SNFs that do not meet care planning and discharge planning requirements and to hold these SNFs accountable Link payments to meeting quality of care requirements Follow up on the SNFs that failed to meet care planning and discharge planning requirements and that provided poor quality of care
20
Compendium of Priorities Questionable hospitalizations CMS should develop a quality measure that describes nursing home rates of resident hospitalization and instruct State agency surveyors to review nursing home rates of resident hospitalization as part of the survey and certification process. CMS should assess whether survey and certification processes offer adequate safeguards against unnecessary antipsychotic drug use in nursing homes, Inappropriate drug use Explore alternative methods for the survey and certification process to promote compliance with established Federal standards regarding unnecessary drug use in nursing homes Take appropriate action regarding the claims associated with erroneous payments identified in our sample Facilitate access to information necessary to ensure accurate coverage and reimbursement determination
21
Questions?
22
Thank you Carrie S. Gilbert Dressman Benzinger LaVelle psc cgilbert@dbllaw.com 859-341-1881
Similar presentations
© 2024 SlidePlayer.com Inc.
All rights reserved.