admin | Health Care Pulse

CMS Plans to Expand Five-Star Rating System Beyond Nursing Homes

By admin on August 13, 2014

Dr. Patrick Conway, a deputy administrator at the Centers for Medicare and Medicaid Services (CMS) announced on CMS’s blog in June that the agency plans to add a star rating system later in 2014 and early in 2015 for several other health care providers. According to Conway, CMS plans to add a star rating system to the Hospital Compare, Dialysis Facility Compare, and Home Health Compare websites. The Nursing Home Compare website already uses star ratings, and the Physician Compare website just started to include star ratings for certain physician group practices.

CMS launched the five-star system for nursing homes in December 2008. The overall five-star rating for each nursing home is based upon the star ratings for three separate categories: 1) health inspections; 2) quality measures; and 3) staffing. To determine a nursing home’s overall rating, CMS begins with the facility’s health inspection rating and then adds or subtracts “stars” depending on the facility’s staffing rating and its quality measures rating. Thus, a facility’s overall rating is an aggregate of its scores in these three areas.

Although CMS intended that consumers use the five-star rating system to help them choose nursing homes, the system has been used beyond its intended purpose. For example, in tort cases against a facility, attorneys for nursing home residents and/or family members frequently attempt to introduce into evidence the nursing home’s five-star rating. It is possible that the same situation will occur with the five-star rating system CMS intends to launch for hospitals, dialysis facilities, and home health companies. However, CMS never intended that the five-star nursing home rating system should serve as a standard of care. In fact, CMS states that the quality measures (one of the components of the five-star rating) on Nursing Home Compare “[a]ren’t benchmarks, thresholds, guidelines, or standards of care, and aren’t appropriate for use in a lawsuit.”

Filed under Five-Star Rating System, Nursing Homes

Face-to-Face Documentation Remains Home Health Compliance Risk Area

By admin on August 6, 2014

The home health face-to-face documentation requirement remains a compliance risk area as evidenced by recent government activity. The Patient Protection and Affordable Care Act changed the home health payment requirements as of Jan. 1, 2011, to require a physician or certain nonphysician practitioners to have and document a face-to-face encounter prior to certifying the patient’s eligibility for home health services. 42 C.F.R. § 424.22(a)(1)(v). This requirement, which is a condition for payment, mandates that the face-to-face encounter occur within a certain timeframe and include an explanation of why the clinical findings support that the patient is homebound and needs intermittent skilled nursing services or therapy services.

In April 2014, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) studied compliance with the face-to-face documentation requirement for home health, concluding there was limited compliance with this requirement. OIG, “Limited Compliance with Medicare’s Home Health Face-to-Face Documentation Requirements,” April 2014. The OIG found that 32 percent of home health claims that required face-to-face encounters did not meet Medicare documentation requirements, resulting in $2 billion in payments that should not have been made. The deficient claims had no face-to-face documentation or had face-to-face documentation that lacked at least one of the required elements. The OIG also found that physicians were inconsistent in completing the narrative content on the face-to-face documentation, even though the Centers for Medicare and Medicaid Services (CMS) provided an example of how this can be accomplished in as little as three sentences.

On July 7, 2014, CMS issued a proposed rule modifying the face-to-face documentation requirement. 79 Fed. Reg. 38366 (July 7, 2014). CMS proposed three changes to the face-to-face encounter requirements.

1) CMS proposes to eliminate the physician narrative requirement. The physician would still certify that a face-to-face encounter occurred with a physician or allowed nonphysician practitioner.

2) CMS proposes that to determine whether the patient is or was eligible to receive Medicare home health services, CMS will review “only the medical record for the patient or the acute/post-acute care facility … used to support the physician’s certification of patient eligibility.” If the patient’s medical record used by the physician to certify eligibility was not “sufficient” to demonstrate the patient was eligible to receive home health services, CMS will not pay for the services.

3) CMS proposes that physician claims for certification/re-certification of eligibility for home health services would not be covered if the home health agency’s claim was not covered because the patient was not eligible for home health services due to an incomplete certification/recertification or insufficient documentation. This change will be implemented through subregulatory guidance.

Although CMS claims that the changes will simplify the face-to-face documentation requirement by eliminating the physician narrative, it also expects that there should be sufficient evidence in the patient’s medical record to demonstrate that the patient is eligible for the home health benefit. However, to date, CMS has not provided guidance on what constitutes “sufficient” documentation. The deadline to file comments to the proposed rule is 5 p.m. on Sept. 2, 2014.

Until a final rule is in effect, home health agencies must comply with the current regulatory requirements for face-to-face encounter documentation. CMS has issued various documents that can assist in completing the face-to-face documentation, including a Medicare Learning Network (MLN) newsletter discussing the documentation requirements, as well as answers to 49 questions about the face-to-face encounter documentation requirements. Home health agencies should review this guidance in conjunction with their policies and procedures to ensure compliance with the face-to-face documentation requirement.

Filed under Face-to-Face Documentation Requirements, Home Health Agencies

Eleventh Circuit Affirms Conviction Against Nursing Home Owner Brought Under Worthless-Services Theory

By admin on August 4, 2014

In United States v. Houser, No. 12-14302, June 24, 2014, the 11th U.S. Circuit Court of Appeals affirmed the conviction of a nursing home operator for conspiring with his wife to defraud the Medicare and Medicaid programs by billing for criminally worthless services, as well as for payroll tax fraud and failure to pay personal tax returns.

The trial court’s order of conviction states that the government proved beyond a reasonable doubt that three nursing facilities operated by the defendant submitted or caused to be submitted false or fraudulent claims to the Medicare and Medicaid programs for worthless services because the services were not provided, were deficient, inadequate, substandard, did not promote the maintenance or enhancement of the residents’ quality of health, and were of a quality that failed to meet professionally recognized standards of health care. The 11th Circuit adopted the trial court’s description of the nursing homes’ conditions as “barbaric” and “uncivilized.” According to the Department of Justice, this was the first conviction following a trial in federal court for submitting claims for worthless services.

On appeal, the 11th Circuit rejected the defendant’s argument that attaching the worthless-services concept used in civil actions on to the federal health care fraud statute makes the statute unconstitutionally vague because it is not possible to determine at what point health care services have crossed the line from bad to criminally worthless. While the appeals court did not endorse or adopt the worthless-services theory, it upheld the conviction because certain required services were not provided to residents at all.

This decision is noteworthy because it shows that the government will go to great lengths to prosecute quality of care cases, including developing new ways to prosecute health care fraud. This trend will likely continue, especially in light of the Department of Health & Human Services (HHS) Office of Inspector General (OIG) 2013 report identifying problems with the quality of care in nursing homes. OIG, “Skilled Nursing Facilities Often Fail to Meet Care Planning and Discharge Planning Requirements,” Feb. 2013.

Filed under Medicaid, Medicare, Nursing Homes, Worthless-Services Theory

D.C. Circuit Upholds Privilege for Internal Compliance Investigations

By admin on July 28, 2014

A recent decision reaffirming that the attorney-client privilege applies to internal compliance investigations should be of interest to health care providers. In In re: Kellogg Brown & Root, Inc., No. 14-5055 (June 27, 2014), the U.S. Court of Appeals for the District of Columbia vacated a trial court order requiring a company to produce its internal investigation documents, which the company claimed were protected by the attorney-client privilege. This decision provides a timely reminder that health care clients should revisit their corporate compliance program requirements and policies to protect compliance activities covered by the attorney-client privilege.

In rejecting the lower court’s ruling that the company’s compliance investigation was not protected by the attorney-client privilege, the court’s discussion of the attorney-client privilege is of interest to any company that conducts internal investigations.

An attorney’s status as in-house counsel does not dilute the attorney-client privilege. The appeals court rejected the lower court’s reasoning that outside counsel must be involved in an internal investigation before the attorney-client privilege applies. Thus, the appeals court concluded that the attorney-client privilege can apply when an internal investigation is conducted by in-house attorneys without consulting outside counsel.
Investigations conducted by non-attorneys at the direction of attorneys can be protected by the attorney-client privilege. The appeals court noted that the investigation in this case was conducted at the direction of attorneys in the corporation’s legal department and that communications made by and to non-attorneys serving as agents of attorneys in internal investigations are routinely protected by the attorney-client privilege.
A company is not required to use “magic words” to protect the investigation under the attorney-client privilege. The lower court ruled that the privilege did not protect the internal investigation because the employees were not informed that the purpose of the interview was to assist the company in obtaining legal advice. The appeals court rejected this reasoning, clarifying that a company is not required to use specific words to gain the benefit of the privilege. The appeals court also noted that in this case the employees knew the company’s legal department was conducting a sensitive investigation; that the information employees disclosed would be protected; and that the employees were told not to discuss their interviews without the general counsel’s advance, direct authorization.
An internal investigation made in compliance with federal regulations does not mean that the investigation was for a business purpose rather than to obtain or provide legal advice. The appeals court emphasized that the attorney-client privilege applies if obtaining or providing legal advice was one of the significant purposes of the internal investigation, even if there were other purposes for the investigation, the investigation was mandated by regulation, and the investigation did not occur at the company’s discretion. Thus, as long as one of the significant purposes of the internal investigation was to obtain or provide legal advice, the attorney-client privilege applies even if the internal investigation was conducted pursuant to a company compliance program required by statute or regulation, or was conducted pursuant to company policy.

This decision is an important development for health care providers that have compliance programs and conduct internal investigations. However, health care providers should review their internal investigation processes to ensure that any internal investigation will be protected by the attorney-client privilege. Among the issues that health care providers should address include the following.

Review policies and procedures to make sure that they explain the process for conducting internal investigations that are covered by the attorney-client privilege, including a statement that these investigations are for the purpose of obtaining or providing legal advice.
Contact counsel, whether in-house or external, promptly when it becomes necessary to conduct an internal investigation.
Attorneys should direct the investigation.
Document that an attorney is involved in the investigation for the purpose of obtaining or providing legal advice.
While there are no “magic words” required to protect an investigation under the attorney-client privilege, all employees who are interviewed should be informed that the company is conducting an investigation to gather facts for the purpose of providing or obtaining legal advice, that the information discussed in the investigation should remain confidential, that the attorney represents the company, and that the conversation is protected by the attorney-client privilege.
Counsel should be included in communications, including e-mails and phone calls.
Documents should be marked to indicate that they are privileged attorney-client communications.

Filed under Attorney-Client Privilege, Health Care Providers, Internal Compliance Investigations

CMS’ Interpretive Guidance for Nursing Homes on Reprocessed Single-Use Devices and Egg Preparation

By admin on July 21, 2014

The Centers for Medicare and Medicaid Services (CMS) recently issued interpretive guidance in two areas of interest for nursing homes: use of reprocessed single-use devices and preparation of eggs in nursing homes. Nursing homes should become familiar with these guidance documents to avoid survey deficiencies.

CMS revised its guidance regarding use of single-use devices: S&C Memorandum No. 14-25-NH, “Advance Copy — Single Use Device Reprocessing under Tag 441, Revisions to Interpretative Guidance in Appendix PP, State Operation Manual (SOM) on Infection Control,” issued May 9, 2014. CMS made this revision to be consistent with current Food and Drug Administration (FDA) regulation that allows the reprocessing and marketing of single-use devices under specific conditions. Nursing homes may purchase reprocessed single-use devices when these devices are reprocessed by an entity or a third-party reprocessor that is registered with the FDA. CMS states that the nursing home must have documentation from the third-party reprocessor indicating that it has been cleared by the FDA to reprocess the specific device in question.

CMS also has revised its interpretative guidance and procedures relating to egg preparation in nursing homes: S&C Memorandum No. 14-34-NH, “Advance Copy of Revised F371; Interpretive Guidance and Procedures for Sanitary HC BLOG_eggs Conditions, Preparation of Eggs in Nursing Homes,” issued May 20, 2014. Nursing homes should use pasteurized shell eggs or liquid pasteurized eggs to eliminate the risk of residents contracting Salmonella Enteritidis. Using pasteurized eggs allows nursing homes to meet resident preferences for soft-cooked, undercooked, or sunny-side up eggs. CMS has stated that nursing homes should not prepare or serve soft-cooked, undercooked, or sunny-side up eggs from unpasteurized eggs. Unpasteurized eggs must be cooked until the yolk and the white are completely firm. For all other forms of egg preparation, including hot holding of eggs and eggs used as an ingredient before baking (such as in cakes or meat loaf), the nursing home must use pasteurized eggs or cook the food item to an internal temperature of 160 degrees.

Nursing homes should also take note of guidance issued to surveyors relating to egg preparation. Signed health release agreements between the resident (or the resident’s representative) and the facility acknowledging that the resident has accepted the risk of eating undercooked unpasteurized eggs are not permitted. Thus, if the nursing home prepares or serves unpasteurized or undercooked eggs — eggs that do not have a completely firm yolk and white — CMS has instructed surveyors to consider citing deficiencies at F371.

Image courtesy of Flickr by Brenda Gottsabend

Filed under Centers for Medicare and Medicaid Services, Egg Preparation, Medicaid, Medicare, Nursing Homes, Reprocessed Single-Use Devices

Growth in Independent Freestanding Emergency Rooms Leads to Concerns

By admin on July 10, 2014

Colorado and the rest of the country have seen a growing number of freestanding emergency rooms. Freestanding emergency rooms are standalone facilities physically separate from a hospital that provide emergency services. Some freestanding emergency rooms are part of a hospital system — an offsite location of a hospital. Independent freestanding emergency rooms are not affiliated with a hospital; they are independent facilities that provide emergency services. It is the independent freestanding emergency rooms that have been the target of much of the recent concerns and criticisms.

HC BLOG_ER One important distinction between independent freestanding emergency rooms and freestanding emergency rooms affiliated with a hospital system involves Medicare reimbursement and regulatory compliance issues. Medicare does not certify freestanding emergency rooms or recognize them as departments. Therefore, independent freestanding emergency rooms cannot receive the Medicare facility fee. However, emergency departments that are affiliated with a hospital can operate as a provider-based hospital department and receive Medicare reimbursement. 42 C.F.R. §§ 482.1 through 482.57. Finally, the Emergency Medical Treatment and Labor Act (EMTALA) — setting out requirements regarding the treatment and transfer of emergency patients — only applies to hospitals participating in federal health care programs. 42 C.F.R. § 489.24.

In 2008, the Centers for Medicare and Medicaid Services (CMS) recognized the emerging trend of freestanding emergency departments and issued a memorandum on this issue to state survey agency directors. CMS Directive S&C-08-08, “Requirements for Provider-Based Off-Campus Emergency Departments and Hospitals That Specialize in the Provision of Emergency Services,” Jan. 11, 2008. CMS noted that it had occasionally encountered interest from providers that want to participate in Medicare as a hospital that specializes in emergency services (distinct from a dedicated emergency department that might be located off the main hospital campus as described at 42 C.F.R. § 489.24(b)).

The CMS memorandum indicated that an emergency services hospital must demonstrate that it satisfies the statutory definition of a hospital found in section 1861(e) of the Social Security Act, including the requirement that the provider is primarily engaged in the provision of services to inpatients. If an applicant specializes in emergency services, CMS stated that it would pay particular attention to the size of the applicant’s emergency department compared to its inpatient capacity. CMS interpreted the statutory requirement that a hospital be primarily engaged in the provision of inpatient services to mean that the provider devotes 51 percent or more of its beds to inpatient care. CMS stated that it would examine other factors in addition to the bed ratio, but the burden is on the applicant to show that inpatient care is the primary health care service. Based on this memorandum, it is unlikely that an independent freestanding emergency room will succeed in being recognized under Medicare as a hospital that specializes in emergency services.

While the number of hospital emergency rooms has declined, emergency room visits have increased. According to a study in the Journal of the American Medical Association, the total number of hospital-based emergency rooms declined 3.3 percent from 1998 to 2008, while emergency department visits increased by 30 percent. Emergency department visits by publicly insured and uninsured patients increased at an even faster pace. The study identified several risk factors for emergency department closure, including safety-net status. This finding is concerning, the study points out, as the number of individuals covered by Medicaid and other forms of public insurance is likely to increase with health care reform. Therefore, the closure of safety net emergency rooms is of grave concern. As a Kaiser Health News article explains, these emergency rooms are not being replaced. The independent freestanding emergency rooms that have recently opened tend to be located in suburban areas, often near high-end shopping centers, and target patients with private insurance.

A Denver Post article describes how freestanding emergency rooms are drawing legislation and critics. A bill proposing new licensing standards for emergency rooms that are not affiliated with a hospital was introduced in the Colorado Senate in 2014. The original bill would have required an independent freestanding emergency room to be located more than 25 miles from a hospital or, if less than 25 miles from a hospital, the bill would have required the independent freestanding emergency room to become affiliated with a hospital within two years of the bill’s effective date. Although the legislation was amended to allow independent freestanding emergency rooms, but included requirements such as serving all patients regardless of ability to pay, the bill did not pass.

The Colorado legislation appears rooted in ongoing criticism of independent freestanding emergency rooms. Much of the concern has centered on cost-related issues. Potential patients often choose to visit a freestanding emergency room with its longer hours and shorter waiting times, even though their problems are non-urgent or semi-urgent, because they cannot get an appointment with their primary care doctor or a nearby urgent care center is closed. Thus, insurers must pay higher fees for services that could have been treated more cost-effectively. While patients have a higher co-payment for emergency services, it is likely that it is not significantly higher to offset the convenience of a freestanding emergency center.

As health care reform evolves, it is likely that independent freestanding emergency rooms will be the target of regulators in Colorado and elsewhere.

Image courtesy of Flickr by Eric Heath

Filed under Centers for Medicare and Medicaid Services, Freestanding Emergency Rooms

Proposed Rules Expand OIG’s Exclusion Authority and Revise Civil Monetary Penalties

By admin on July 3, 2014

In May, the Department of Health and Human Services Office of Inspector General (OIG) proposed changes to the OIG’s exclusion authority and ability to impose civil monetary penalties (CMPs). The proposed rules codify the changes made by the Affordable Care Act, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, and other statutory authorities.

The first rule proposes to expand the OIG’s exclusion authority in accordance with the Affordable Care Act (ACA). 79 Fed. Reg. 26810. The comment period for this proposed rule ends July 8. The OIG proposes that the following new conduct would subject a person to permissive exclusion:

conviction of an offense in connection with obstructing an audit;
failing to supply payment information; and/or
making or causing to be made any false statement, omission, or misrepresentation of a material fact on an application to a federal health care program.

The OIG’s proposed rule makes several additional changes, including the following:

an early reinstatement process for certain individuals who lost their health care licenses; and
expanding the list of individuals and entities entitled to present oral argument to the OIG before being excluded from federal health care programs.

The proposed rule also clarifies that there is no statute of limitation period for exclusions.

The second proposed rule expands the OIG’s ability to assess CMPs. 79 Fed. Reg. 27080. The comment period for this proposed rule ends July 11. The proposed rule adds penalties for the following conduct:

failing to grant OIG timely access to records following a reasonable request;
ordering or prescribing while excluded from federal health care programs when the excluded person knew or should know the excluded item or service may be paid for by a federal health care program;
making false statements, omissions, or misrepresentations in an enrollment or similar application to participate in a federal health care program;
failing to report and return a known overpayment; and/or
making or using a false record or statement that is material to a false or fraudulent claim.

The OIG is soliciting comments about its proposed clarification of the penalty for failing to report and return a known overpayment. Under the ACA, overpayments must be reported and returned by the later of 60 days after the date the overpayment was identified or the date any corresponding cost report is due, if applicable.

The new CMP provision does not have a specific penalty amount, but uses the default penalty of up to $10,000 for each item and service. The OIG has proposed a penalty of up to $10,000 for each day a person fails to report and return a known overpayment by the deadline. Noting that Congress did not specify a per day penalty, the OIG also has requested comments on whether to interpret the $10,000 penalty for each item and service as pertaining to each claim for which the provider or supplier identified an overpayment.

Health care providers should continue to monitor the OIG’s rulemaking in the fraud and abuse area as the OIG continues to implement changes as a result of the ACA.

Filed under Civil Monetary Penalties, OIG Exclusion Authority

The OIG’s Anti-Kickback Concerns on Contracts Between Senior Communities and Placement Agencies

By admin on June 30, 2014

The Office of Inspector General (OIG) of the Department of Health & Human Services (HHS) has issued an advisory opinion about whether senior communities that paid a placement agency for referring new residents violated the federal anti-kickback statute. OIG Advisory Opinion No. 14-01. Although the OIG did not impose sanctions, the opinion highlights the risks inherent in these types of arrangements.

A nonprofit organization that owns subsidiaries involved in senior housing and geriatric care, including senior residential communities and skilled nursing facilities, requested an advisory opinion about the relationship between two residential communities and a placement agency. The placement agency contracted with the two communities to promote their available housing and place new residents with them. Under the agreement the placement agency receives a fee for every new resident it places at one of the communities. The fee is based on a percentage of a new resident’s initial charges and does not include any charges billed to federal health care programs. In addition, the contracts prohibited the placement agency from referring new residents who rely on state or federal health care money and do not allow the communities to accept any referrals of residents who receive state or federal health care money.

The communities did not provide services reimbursed by Medicare, no residents who were referred received services provided under a Medicaid waiver program, and none of the residents received therapy from skilled nursing facility staff. Although none of the residents who were referred by the placement agency received federally payable services at the time of the referral, it was possible that the residents could receive federally payable services by an affiliated entity in the future.

Although the OIG found that there was remuneration that implicated the anti-kickback statute, it concluded that the facts and circumstances of the arrangement adequately reduced the risk that the payment provided under the contract could be an improper payment for referrals or the generation of federal health care program business. The placement fee does not include any charges to the federal health care programs. In addition, the contract prohibits the placement agency from referring and the communities from accepting any residents who rely on state or federal health care programs. The placement agency does not refer residents for services and housing that are paid by federal health care programs, nor does it limit a resident’s choice of provider. Finally, the parent company certified that its affiliated entities do not track referrals or common residents or providers.

The OIG’s opinion highlights the risks of referral-based payment arrangements. By paying the placement fee, the communities paid remuneration that implicates the anti-kickback statute because the residents may later receive care reimbursed by federal health care programs. Percentage compensation arrangements are problematic under the anti-kickback statute because they relate to the volume and value of the business between the parties. However, due to the unique circumstances of this matter — including that the entities certified they did not track referrals to determine which residents eventually received Medicare and Medicaid services — the OIG found that the remuneration was not likely to be an improper payment to generate federal health care program business.

Of note, the OIG’s advisory opinion did not extend to a community that at one time had residents who had access to federally payable on-site therapy services provided by staff from a skilled nursing facility. Health care providers that enter volume- and value-based contracts should proceed with caution: The OIG’s advisory opinion is tied to a specific and narrow set of facts

Filed under Medicaid, Medicare, Nursing Homes, OIG Advisory Opinion, Placement Agencies

OIG Issues Priority Recommendations Highlighting Focus Areas

By admin on June 24, 2014

The U.S. Department of Health and Human Services’ Office of Inspector General (OIG) recently released the OIG Compendium of Priority Recommendations. The OIG derives its 25 priority recommendations from more specific recommendations that the OIG has made in audit and evaluation reports but has not yet implemented. The recommendations cover 25 broad areas and provide insight into the OIG’s focus areas. According to the OIG, the “recommendations represent opportunities to achieve cost-savings, improve program management, and ensure quality of care and safety of beneficiaries. …” Health care providers should review the OIG recommendations to assist in focusing compliance efforts.

The OIG’s recommendations fall into seven broad categories: HC BLOG_hospice

1. Medicare Policies and Payments;

2. Medicare Quality of Care and Safety Issues;

3. Medicaid Program Policies and Payments;

4. Medicaid Quality of Care and Safety Issues;

5. Oversight of Food Safety;

6. HHS Grants and Contracts; and

7. HHS Financial Stewardship.

Below is a summary of selected recommendations that affect senior providers, hospice, and home health.

Hospice care in nursing homes – The OIG expresses concern that Medicare’s hospice payment methodology may lead some hospices to inappropriately seek out beneficiaries in nursing homes. As the OIG notes, Medicare pays hospices an all-inclusive daily rate regardless of the number of services furnished. The OIG identified hundreds of hospices that had more than two-thirds of their beneficiaries residing in nursing facilities in 2009.

The OIG recommends monitoring hospices that depend heavily on nursing facility residents. In addition, the OIG recommends modification of the payment system for hospice care in nursing facilities, including statutory authority if necessary.

Home health services: billing practices – The OIG expressed concern about home health agencies’ billing practices, noting that one review found one in four home health agencies exceeded a threshold that indicated unusually high billing for at least one of six measures of questionable billing.

As a result of this finding, the OIG’s recommendations include increasing monitoring of billing of home health services and taking action regarding inappropriate payments and questionable billing.

Skilled nursing facilities: billing practices – According to the OIG, skilled nursing facilities have a number of billing problems. The OIG states that these problems include submitting inaccurate, medically unnecessary, and fraudulent claims, concluding that in 2009 skilled nursing facilities billed one-quarter of their claims in error.

The OIG has several recommendations to remedy skilled nursing facilities’ billing problems, such as increasing and expanding review of claims, monitoring compliance with new therapy assessments, and strengthening monitoring of skilled nursing facilities that disproportionately bill for higher paying resource utilization groups.

Nursing homes: patient harm, questionable resident hospitalizations, and inappropriate drug use – The OIG found a number of problems with nursing homes. According to the OIG’s findings, about 33 percent of Medicare beneficiaries experienced adverse or temporary harm events during their stay. Fifty-nine percent of these events were clearly or likely preventable, and the OIG found that these events resulted from substandard treatment, inadequate resident monitoring, and failure or delay of necessary care. The OIG also found that nursing homes had questionable hospitalizations and safeguards against unnecessary antipsychotic drug use.

The OIG made several specific recommendations to combat the nursing home problems that it identified. The recommendations include instructing nursing home surveyors to review facility practices for identifying and reducing adverse events, instructing surveyors to review nursing home hospitalization rates, and having the Centers for Medicare and Medicaid Services assess whether survey and certification processes offer adequate safeguards against unnecessary antipsychotic drug use in nursing homes.

Other recommendations – Health care providers should review the OIG’s entire list of priority recommendations to determine which recommendations apply to them. The recommendations provide a useful starting point for targeted compliance activities.

Filed under Health Care Providers, Medicaid, Medicare, Nursing Homes

The Top 10 Assisted Living Deficiencies

By admin on June 19, 2014

Last year, the Assisted Living Federation of America (ALFA) conducted a state-by-state assessment of the most common regulatory citations in assisted living communities. The results of the 2013 Top 10 Deficiencies Report can help assisted living facilities in their regulatory compliance efforts.

3926259585_5f265f6683_z ALFA contacted each state’s regulatory agency to compile a list of the 10 most common assisted living citations. The deficiencies were placed in one of 17 categories, making it possible to compare deficiencies across states.

ALFA found several deficiencies that were common across states. Medication administration was the most commonly cited deficiency, reported in 76 percent of states. This deficiency citation includes not providing medication as directed, having an outdated physician order, and incorrect medication administration documentation. Other common deficiencies across states include admission requirements (66 percent of states), ongoing resident assessment (62 percent of states), and resident care (62 percent of states).

ALFA found that the 10 most commonly cited deficiencies in Colorado are the following:

compliance with physician orders (medication administration);
medication storage;
policies and procedures (medication storage);
interior and exterior environment (maintenance and building code);
food service sanitation;
written orders (medication administration);
background checks — other staff and volunteers;
administration of medication and treatment;
current first-aid certification; and
administration of medication

Based on ALFA’s assessment, six out of the 10 most common deficiencies relate to medication administration.

Assisted living facilities should focus compliance efforts, including training, audits, and policy development, on the commonly cited deficiencies, particularly medication administration

Image courtesy of Flickr by Charles Williams

Filed under Assisted Living Regulatory Citations

← Older posts

Newer posts →