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Skilled Nursing Facility and Nursing Home Initiatives – OIG 2017 Annual Work Plan

Thursday, January 19th, 2017

Skilled Nursing Facility and Nursing Home Initiatives
OIG 2017 Annual Work Plan

The OIG’s 2017 Annual Work Plan identified a few new areas of focus relating to nursing homes and skilled nursing facilities. Nursing home compliance officers should consider these newly identified issues when developing their annual compliance work plan.

Investigation of Serious Nursing Home Conditions

The Work Plan references a 2006 OIG report which found that state agencies failed to investigate in a timely manner some of the most serious complaints regarding nursing home conditions. The report referenced nursing home complaints involving immediate jeopardy and/or actual harm to residents. Complaints that rise to this level of severity are to be investigated by applicable state agencies within a 2 and 10 day timeframe. The Work Plan states that OIG will determine the extent to which State agencies investigate serious nuring home complaints within the required timeframes. Nursing homes can expect this to put more pressure on states that are responsible for these investigations to meet these timeframes on a more regular basis.

Unreported Incidents of Potential Abuse and Neglect

This newly identified topic relates to skilled nursing facilities. The OIG states that is plans to “assess” the incidence of abuse and neglect that occurs in skilled nursing facilities. It then plans to make a determination whether these incidents were properly reported and investigated as required under applicable Federal and state law. It appears that the OIG will be taking a sampled representation of cases to investigate. This conclusion can be garnered from reference in the Work Plan to “sampled” incident reports. The OIG plans to interview state officials to assure that incident reports that are examined under its sampling system were reported as required under law. The OIG plans to go even further and determine whether each reportable incident was investigated and subsequently prosecuted by the state.

This area could create some immediate risk exposure to facilities who are sampled as part of the OIG’s investigation. Facilities who are found to have failed to appropriately report potential abuse and neglect incidents could be subject to sanctions.

Review of SNF Use of Minimum Data Set Tool

the OIG states that it will review documentation of selected Skilled Nursing Facilities to determine whether Minimum Data Set Tool have been properly used to determine the severity of the patient’s condition. SNF reimbursment is tied to the severity of the patient’s condition through application of this tool. Periodic assessments must be performed on each patient by applicable skilled nursing facility. Improper use of the tool results in higher reimbursment than may be justified by the patient’s condition.

This issue was called out by previous OIG studies that indicated higher levels of reimbursement were being paid due to improper use of the Minimum Data Set Tool. Again, this is an area of specific concern for facilities who are lucky enough to be selected for audit by the OIG. If the facility is found to have improperly assessed patient severity, overpayment and potential penalties may be imposed. A finding on a small sample could also lead to expansion past the initially reviewed cases.

Major Revamp of Nursing Home Regulations Proposed By CMS

Friday, July 17th, 2015

Nursing Home Regulations Proposed Revision CMSThe Centers for Medicare & Medicaid Services (CMS) has release new proposed regulations that would implement the first major rewrite of the long-term care Conditions of Participation in over 25 years. The proposed regulations were published on On July 13, 2015 in proposed form and are subject to a 60 day comment period before CMS issues them in final form. It is possible that CMS would revise the proposed rules based on input from the public duringthe comment period.

By changing nursing home regulations, CMS intends to improve the quality of care and safety affecting long-term care residents. The proposed changes would implement a number of safeguards including some protections that were required under the Affordable Care Act.

Providers involved in the nursing home industry should study the proposed regulations and may wish to provide comments to CMS to be addressed prior to finalization of the proposed regulations. Some of the items addressed in the proposed regulations include:

– Regulations regarding reduction of unnecessary hospital readmissions and infections

-increased quality of resident care

– New requirements to assure training of nursing home staff

– increased focus on patients with dementia and prevention of elder abuse.

– New rules regarding staffing decisions.

– Rules that help assure that staff members have the right skill sets and competencies to provide person-centered care to residents.

– Increased emphasis on resident preferences when developing care plans.

– Improvements to the process of care planning and discharge planning

– Increased authority of dietitians and therapy providers to write orders in their areas of expertise subject to physician delegatino and state law compliance.

– Requiring greater food choice for residents.

– Updating of infection prevention and control programs and establishment of new requirements for infection prevention and control.

– Enhancement of nursing home resident rights

More details can be obtained by reviewing the proposed regulations. We will be issuing additional updates regarding topics that are covered in the proposed regulations as we review the proposal in greated depth.

Referral Fee Fine Despite Kickback Concerns – OIG Advisory Opinion 14-01

Friday, January 24th, 2014

Independent Placement Agency Fee By Senior House Approved By OIG

senior housing kickback oig opinionThe Office of Inspector General posted its first advisory opinion of the year this past Tuesday.  OIG Advisory Opinion No. 14-01 responds to a nonprofit senior housing and geriatric care provider’s question of whether it may pay an independent placement agency a fee for referring new residents to its facilities.  Despite concerns that the arrangement could potentially generate prohibited remuneration under the anti-kickback statute, the OIG opinion states it would not impose sanctions in connection with the arrangement.

Here’s the facts:

  • The senior care provider operates 11 senior residential communities, two skilled nursing facilities, and a management company.
  • The residential communities offer to their residents various services – including skilled nursing services (e.g. wound care) and help with daily living activities (e.g. housekeeping).
  • A Medicaid program pays for services provided to residents in three of the residential communities.  Other than this, the skilled nursing facilities are the only entities that provide federally reimbursed health care services to residents.
  • Two of the residential communities pay an independent placement agency for referring new residents.  The placement agency receives a fee for every referral – a percentage of the new resident’s charges for his or her initial month or two.
  • The placement agency is prohibited from referring, and the residential communities are prohibited from accepting, residents who are known to rely on Medicaid, Medicare, or other state or federal funding.
  • Neither of the residential communities provide services reimbursed by Medicare.

Although the two residential communities pay a placement fee for a resident who may in the future receive federally reimbursed services from one of the senior care provider entities (which would potentially be illegal remuneration under anti-kickback laws), the OIG advisory opinion indicates that this referral arrangement is fine because:

  1. The placement fee is calculated only considering initial rent and services.
  2. The contracts underlying the arrangement prohibit both placement and acceptance of potential residents who are known to rely on government funding for their health care.
  3. Neither of the residential communities using the referral arrangement provide services reimbursed by Medicare.
  4. The senior care provider does not track referrals or common residents or patients nor do they limit their residents’ choice of providers.

Please feel free to contact John Fisher, CHC, CCEP, in the Ruder Ware Health Care Industry Focus Group for more information.

Fraud Risks In Nursing Home/Hospice Relationships

Wednesday, October 30th, 2013

Fraud Risks Between Nursing Homes and Hospice Providers

Hospice Nursing Home Fraud and AbuseRelationships between hospices and nursing homes are a particular area of concern.  OIG is inherently suspicious of benefits that hospices may provide to nursing homes in order to gain hospice referrals of nursing home patients.  For example, if a hospice provides services to nursing home patients that are normally provided by the nursing home, the benefit could be deemed to be a “kickback” for referrals.  Hospices should have clear policies and procedures regarding the scope of services to be provided to nursing home patients.  Any formal agreement with a nursing home should be carefully scrutinized to assure compliance and provision should be added agreeing to the appropriate scope of care that is to be provided to nursing home patients.

Government focus on hospice providers should heighten awareness to these issues.  Hospices must make certain that they have formal compliance programs in place and that the compliance program is actively operated to identify and address risk.  Certainly, the risks identified above should be addressed by all hospice providers.  There are a broad range of additional items that should be actively addressed.  Additionally, all elements of the compliance program should be fully operationalized.  Even the most robust compliance program will not necessarily detect all compliance problems.  It is important that hospice providers are able to demonstrate that they are continually monitoring risk and operating their program.  When undetected programs come to light, the hospice provider will be able to show that reasonable steps are routinely taken to identify and correct problems.  This will go a long ways toward reducing potential exposure, even in cases where risk is not detected through the program.

Hospice and Home Health Areas of Review Risk

Wednesday, September 18th, 2013

Home Health and Hospice Review Areas

home health hospice fraud reviewsThere are several areas applicable to home health and hospice that are susceptible to review.  Hospice reviews have tended to focus on whether patients actual meet criteria to be eligible to receive hospice benefits.  The focus on hospice arises, at least in part, due to the expansion of this segment of health care industry and the relatively rapid increase in spending for hospice care.  The government’s audit and enforcement trends indicate a deep suspicion that hospice are admitting patients who are not terminal or do not otherwise meet eligibility criteria.  The government points to the relatively large number of hospice patients who are discharged from hospice care alive.

In order to qualify for hospice benefits, a Medicare patient must have an illness that is terminal.  A physician must certify that the patient is terminal and is unlikely to live longer than six months if the illness runs its expected course.  The patient must also waive their right to receive curative treatment for the terminal condition in order to qualify for benefits.  Physician certification must be provided at two 90-day intervals following hospice admission.  After the first 180 days of hospice care, the patient must be seen “face-to-face” by a nurse practitioner who determines continued eligibility for coverage.  This process of certification and admission qualification creates several obvious pouts of risk for providers.  The government seems to be keying in on a few of these points of risk as evidenced by recent enforcement actions.

Payments to physicians for administrative duties should be carefully scrutinized to assure that the compensation arrangement does not create a referral inducement.  Medical director agreements must be analyzed under the Anti-Kickback Statute and applicable Stark Law exceptions.  Compensation should be at fair market value, cannot take into account he volume or value of referrals, and must meet other regulatory requirements.

Long Term Care Compliance Risk Factors

Friday, April 12th, 2013

Nursing Home Compliance Plan Risk Areas Identified in OIG Guidance from 2000

The OIG Guidance to Nursing Homes relative to their compliance plans was issued in 2000.  That document contained the elements that the OIG felt that Nursing Homes should consider in their compliance plans.  Now that the date has passed and nursing facilities and skilled nursing facilities are required to have adopted effective compliance programs, I thought it might be useful to list some of the risk factors that the OIG felt were important in 2000.  Obviously, these factors are not all inclusive and additional risk areas have been identified since that time.  Yet, the items identified in the 2000 OIG Guidance remains a viable starting point to assist facilities in identifiying risk areas that need to be addressed in their compliance programs.

 

Important Statement from the OIG – This factor should be specifically mentioned in all nursing home compliance plans:

The OIG believes that a nursing facility’s compliance policies should start with a statement that affirms the facility’s commitment to providing the care and services necessary to attain or maintain the resident’s ‘‘highest practicable physical, mental and psychosocial well-being.’’

Additional Factors Relative to Quality

  • accurate assessment of each resident’s functional capacity and a comprehensive care plan that includes measurable objectives and timetables to meet the resident’s medical, nursing, and mental and psychosocial needs;
  • inappropriate or insufficient treatment and services to address residents’ clinical conditions, including pressure ulcers, dehydration, malnutrition, incontinence of the bladder, and mental or psychosocial problems;
  • failure to accommodate individual resident needs and preferences;
  • failure to properly prescribe, administer and monitor prescription drug usage;
  • inadequate staffing levels or insufficiently trained or supervised staff to provide medical, nursing, and related services;
  • failure to provide appropriate therapy services;
  • failure to provide appropriate services to assist residents with activities of daily living (e.g., feeding, dressing, bathing, etc.);
  • failure to provide an ongoing activities program to meet the individual needs of all residents; and
  • failure to report incidents of mistreatment, neglect, or abuse to the administrator of the facility and other officials as required by law.

 

Residents Rights.  To protect the rights of each resident, the OIG recommends that a provider address the following risk areas as part of its compliance policies:

 

  •   discriminatory admission or improper denial of access to care;
  • verbal, mental or physical abuse, corporal punishment and involuntary seclusion;
  • inappropriate use of physical or chemical restraints;
  • failure to ensure that residents have personal privacy and access to their personal records upon request and that the privacy and confidentiality of those records are protected;
  • denial of a resident’s right to participate in care and treatment decisions;
  • failure to safeguard residents’ financial affairs.

Billing Issues.

billing for items or services not rendered or provided as claimed;

  • submitting claims for equipment, medical supplies and services that are medically unnecessary;
  • submitting claims to Medicare Part A for residents who are not eligible for Part A coverage;
  • duplicate billing;
  • failing to identify and refund credit balances;
  • submitting claims for items or services not ordered;
  • knowingly billing for inadequate or substandard care;
  • providing misleading information about a resident’s medical condition on the MDS or otherwise providing inaccurate information used to determine the RUG assigned to the resident;
  • upcoding the level of service provided;
  • billing for individual items or services when they either are included in the facility’s per diem rate or are of the type of item or service that must be billed as a unit and may not be unbundled;
  • billing residents for items or services that are included in the per diem rate or otherwise covered by the third-party payor;
  • altering documentation or forging a physician signature on documents used to verify that services were ordered and/ or provided;
  • failing to maintain sufficient documentation to support the diagnosis, justify treatment, document the course of treatment and results, and promote continuity of care;
  • false cost reports;
  • routinely waiving coinsurance or deductible amounts without a good faith determination that the resident is in financial need, or absent reasonable efforts to collect the cost-sharing amount;
  • agreements between the facility and a hospital, home health agency, or hospice that involve the referral or transfer of any resident to or by the nursing home;
  • soliciting, accepting or offering any gift or gratuity of more than nominal value to or from residents, potential referral sources, and other individuals and entities with which the nursing facility has a business relationship;
  • conditioning admission or continued stay at a facility on a third-party guarantee of payment, or soliciting payment for services covered by Medicaid, in addition to any amount required to be paid under the State Medicaid plan;
  • arrangements between a nursing facility and a hospital under which the facility will only accept a Medicare beneficiary on the condition that the hospital pays the facility an amount over and above what the facility would receive through PPS;
  • financial arrangements with physicians, including the facility’s medical director;
  • arrangements with vendors that result in the nursing facility receiving non-covered items (such as disposable adult diapers) at below market prices or no charge, provided the facility orders Medicare-reimbursed products;
  • soliciting or receiving items of value in exchange for providing the supplier access to residents’ medical records and other information needed to bill Medicare;
  •  joint ventures with entities supplying goods or services;
  •  swapping.

Reimbursement for Telemedicine and Telehealth Services

Thursday, April 11th, 2013

Reimbursement Rules for Telemedicine Slow to Develop

The absence of consistent, comprehensive reimbursement policies has historically been one of the most serious obstacles to the development of telemedicine.  Without uniformity in reimbursement it is much more difficult for providers to develop economically self-sustaining telemedicine programs.  If reimbursement is inconsistent, providers must look to other factors, such as enhancement of efficiencies, to justify the development of new telemedicine technologies.  We are beginning to see changes in state and federal reimbursement for telehealth services, but changes are coming slowly.

All health care reimbursement policy is disjointed between a variety of federal agencies, state governments, and various types of private health care payors.  Reimbursement policies play an important role in determining the rate which new modes of providing care can develop.  CMS policy often sets some of the general rules that other payors look to when setting their reimbursement policies.  Unfortunately, in the area of telehealth coverage, CMS has not taken a progressive approach to developing a reimbursement policy.  Some progress has been made toward expanding Medicare coverage.  Yet, Medicare coverage is still severely limited and is only (with very few exceptions) available to patients that are located in specific rural areas.

Many state Medicaid programs, including Wisconsin’s Badger Care Program, provide more expansive coverage of services that are provided using telemedicine technologies.  Other states have more restrictive coverage.  Private insurance policies vary widely.  Some states have passed laws that mandate telemedicine coverage.  Even of the states that have passed mandatory laws, the nature and scope of the mandate differ widely.

Unfortunately, this inconsistency and unpredictability in reimbursement serves as an impediment to development in telemedicine.  Even when a telemedicine program is developed, reimbursement inconsistencies increase administrative burdens involved with billing for services.  The inconsistencies also necessarily increase compliance risk if the provider is not up to date and accurate as to the reimbursement rules that are applicable.

Nursing Home Compliance Programs – ACA Statutory Mandate

Tuesday, March 26th, 2013

Mandatory Compliance Program Requirements – Affordable Care Act Statutory Mandate

Provisions of Affordable Care Act Relating to Mandatory Compliance Programs For Nursing Facilities

 

SEC. 6102. ACCOUNTABILITY REQUIREMENTS FOR SKILLED NURSING

FACILITIES AND NURSING FACILITIES.

Part A of title XI of the Social Security Act (42 U.S.C. 1301 et seq.), as amended by sections 6002 and 6004, is amended by inserting after section 1128H the following new section:

‘‘SEC. 1128I. ACCOUNTABILITY REQUIREMENTS FOR FACILITIES.

‘‘(a) DEFINITION OF FACILITY.—In this section, the term ‘facility’ means—

‘‘(1) a skilled nursing facility (as defined in section 1819(a)); or

‘‘(2) a nursing facility (as defined in section 1919(a)).

‘‘(b) EFFECTIVE COMPLIANCE AND ETHICS PROGRAMS.—

‘‘(1) REQUIREMENT.—On or after the date that is 36 months after the date of the enactment of this section, a facility shall, with respect to the entity that operates the facility (in this subparagraph referred to as the ‘operating organization’ or ‘organization’), have in operation a compliance and ethics program that is effective in preventing and detecting criminal, civil, and administrative violations under this Act and in promoting quality of care consistent with regulations developed under paragraph (2).

‘‘(2) DEVELOPMENT OF REGULATIONS.—

‘‘(A) IN GENERAL.—Not later than the date that is 2 years after such date of the enactment, the Secretary, working jointly with the Inspector General of the Department of Health and Human Services, shall promulgate regulations for an effective compliance and ethics program for operating organizations, which may include a model compliance program.

‘‘(B) DESIGN OF REGULATIONS.—Such regulations with respect to specific elements or formality of a program shall, in the case of an organization that operates 5 or more facilities, vary with the size of the organization, such that larger organizations should have a more formal program and include established written policies defining the standards and procedures to be followed by its employees. Such requirements may specifically apply to the corporate level management of multi unit nursing home chains.

‘‘(C) EVALUATION.—Not later than 3 years after the date of the promulgation of regulations under this paragraph, the Secretary shall complete an evaluation of the compliance and ethics programs required to be established under this subsection. Such evaluation shall determine if such programs led to changes in deficiency citations, changes in quality performance, or changes in other metrics of patient quality of care. The Secretary shall submit to Congress a report on such evaluation and shall include in such report such recommendations regarding changes in the requirements for such programs as the Secretary determines appropriate.

 

‘‘(3) REQUIREMENTS FOR COMPLIANCE AND ETHICS PROGRAMS.—

In this subsection, the term ‘compliance and ethics program’ means, with respect to a facility, a program of the operating organization that—‘‘(A) has been reasonably designed, implemented, and enforced so that it generally will be effective in preventing and detecting criminal, civil, and administrative violations under this Act and in promoting quality of care; and ‘‘(B) includes at least the required components specified

in paragraph (4).

‘‘(4) REQUIRED COMPONENTS OF PROGRAM.—The required components of a compliance and ethics program of an operating organization are the following:

‘‘(A) The organization must have established compliance standards and procedures to be followed by its employees and other agents that are reasonably capable of reducing the prospect of criminal, civil, and administrative violations under this Act.

‘‘(B) Specific individuals within high-level personnel of the organization must have been assigned overall responsibility to oversee compliance with such standards and procedures and have sufficient resources and authority to assure such compliance.

‘‘(C) The organization must have used due care not to delegate substantial discretionary authority to individuals whom the organization knew, or should have known through the exercise of due diligence, had a propensity to engage in criminal, civil, and administrative violations under this Act.

‘‘(D) The organization must have taken steps to communicate effectively its standards and procedures to all employees and other agents, such as by requiring participation in training programs or by disseminating publications that explain in a practical manner what is required.

‘‘(E) The organization must have taken reasonable steps to achieve compliance with its standards, such as by utilizing monitoring and auditing systems reasonably designed to detect criminal, civil, and administrative violations under this Act by its employees and other agents and by having in place and publicizing a reporting system whereby employees and other agents could report violations by others within the organization without fear of retribution.

‘‘(F) The standards must have been consistently enforced through appropriate disciplinary mechanisms, including, as appropriate, discipline of individuals responsible for the failure to detect an offense.

‘‘(G) After an offense has been detected, the organization must have taken all reasonable steps to respond appropriately to the offense and to prevent further similar offenses, including any necessary modification to its program to prevent and detect criminal, civil, and administrative violations under this Act.

‘‘(H) The organization must periodically undertake reassessment of its compliance program to identify changes necessary to reflect changes within the organization and its facilities.

Nursing Facility Compliance Program Deadline Is Here!

Friday, March 22nd, 2013

Nursing Facilities Must Have Effective Compliance Programs In Place by March 23, 2013

Nursing Home Compliance ProgramsThe statutory deadline requiring nursing facilities to have formal compliance programs in place is upon us.  The Patient Protection and Affordable Care Act (PPACA) requires all nursing facilities and skilled nursing facilities to have formally adopted effective compliance and ethics programs by March 23, 2013.  To date, the Centers for Medicare & Medicaid Services (CMS) has not released final regulations regarding the required elements of nursing facility compliance programs.  However, the failure of CMS to issue final regulations should not deter nursing facilities from adopting compliance programs.  Even though regulations have not been released, the statutory mandate is in place.  Additionally, there is an abundance of guidelines that define what should be included in the compliance progam of a nursing facility. 

It is unclear how the failure of CMS to issue regulations will impact enforcement in this area.  The statute requires effective compliance programs to be in place by March 23, 2013 regardless of whether regulations are released.  Compliance programs are now a “condition of participation” that can be cited in survey reports.  Directions to survery agencies on this issue is not clear, but it is possible that citations could be issued in this area.  Additionally, if a nursing facility is contemplating a transaction, it is likely that the failure to have a compliance program in place by March 23, 2013 will arise in the course of due diligance.

Remember that it is not enough to simply have the appropriate compliance documents in place.  The compliance program must be demonstrated (and certified) to be “effective.”  Documents alone cannot make a compliance program “effective.”  Compliance program effectiveness requires a specific anlysis of both the content and operation of the compliance program.  Compliance programs that do not have a track record of effective operation cannot be considered to be “effective.”  Organizations need to consider what backup they plan to create to meet the certification requirements under PPACA.  Nursing facilities that do not have compliance programs in place need to address this deficiency immediately.  Those that have compliance programs in place need to assess the effectiveness of their programs.  In either event, experienced compliance counsel should be consulted to determine hat is required in order to meet the statutory mandate.

Ruder Ware offers a full range of compliance attorney services.  Health care attorney John Fisher is certified in Health Care Compliance and Corporate Compliance and Ethics and is one of a handful of attorneys in private practice in the country to hold this dual compliance certification.  You can contact Mr. Fisher through the Ruder Ware web site or through the “Contact” section of this blog.

CMS Improvement Standard Case Settlement

Wednesday, January 2nd, 2013

CMS Settles Class Action Reversing Nursing Home Improvement Standard 

 It is being reported that the Center for Medicare Advocacy, Inc. has settled its class action suit with the Center for Medicare and Medicaid Services regarding the “improvement standard” that CMS has historically required in order to continue Medicare reimbursement for patients in nursing homes. The “improvement standard” resulted in Medicare coverage being denied in cases where a patient’s condition was found to be stable, chronic, not improving, or for “maintenance only.”

 The proposed settlement agreement will require CMS to revise relevant portions of its Medicare Benefit Policy Manual to clarify coverage standards for skilled nursing facilities, home health, and outpatient therapy benefits when a patient has not restoration or improvement potential but still needs the services that are provided by those types of providers. CMS is also required to clarify similar coverage standards that are applicable to inpatient rehabilitation facilities.
 The settlement agreement provides for input by counsel representing the class into the process of developing new manual provisions that conform with the settlement.The class action suit has alleged that Medicare routinely denied coverage based on the improvement standard. The settlement will require CMS to clarify that the improvement standard will no longer be applied to deny coverage.
The people most affected by this barrier include people living with a range of conditions including multiple sclerosis, Alzheimer’s disease, ALS (Lou Gehrig’s disease), spinal cord injuries, diabetes, Parkinson’s disease, hypertension, arthritis, heart disease, and stroke. Many of these individuals who were not showing progress but still required care, and the institutions that serve them, will not be able to obtain reimbursement for services that they require.Center for Medicare Advocacy Link

 

John H. Fisher

Health Care Counsel
Ruder Ware, L.L.S.C.
500 First Street, Suite 8000
P.O. Box 8050
Wausau, WI 54402-8050

Tel 715.845.4336
Fax 715.845.2718

Ruder Ware is a member of Meritas Law Firms Worldwide

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