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10-05-2007
2008 OIG Workplan
By Marc Zimmet
The Office of Inspector General (“OIG”) released its 2008 Workplan on October 1, 2007. This publication “describes activities that the Office of Inspector General plans to continue or initiate with respect to the programs and operations of the Department of Health and Human Services.”
This year’s Workplan is perhaps the most comprehensive and far reaching ever issued. The document is 111 pages and applies to a wide range of healthcare providers, payers and suppliers.
We have analyzed the contents and summarized pertinent issues related to skilled nursing facilities below.
We strongly recommend that providers take all steps necessary to ensure compliance with all of these issues. ZHSG is available to advise you on these matters, and perform modest compliance audits on your behalf. These reviews will allow you to target your compliance efforts effectively and efficiently.
The report may be viewed in its entirety at:
http://oig.hhs.gov/publications/docs/workplan/2008/Work_Plan_FY_2008.pdf.
Please feel free to contact our office for more information on the 2008 OIG Workplan.
2008 OIG Workplan
SNF Issues Compiled by Zimmet Healthcare Services Group
1. Accuracy of Coding for Medicare Skilled Nursing Facility Resource Utilization Groups’ Claims:
The OIG will review a national sample of Medicare claims submitted by SNFs to determine the extent to which Resource Utilization Groups (“RUGs”) included on SNF claims for Medicare reimbursement are accurate and supported by the residents’ medical records. A 2006 OIG report found that 22 percent of claims were upcoded, representing $542 million in potential overpayments for FY 2002. As part of follow-up work, OIG will also identify areas to improve the accuracy of payments to SNFs.
Status: OEI; 00-00-00000; expected issue date: FY 2009; new start
2. Therapy Services Provided by Nursing Homes and Comprehensive Outpatient Rehabilitation Facilities:
OIG will review the appropriateness of Medicare claims submitted by comprehensive outpatient rehabilitation facilities (CORF) for physical therapy, speech language pathology, and occupational therapy services. Prior OIG reviews found that Medicare paid significant amounts for unallowable or highly questionable therapy services in outpatient rehabilitation facilities and nursing homes. A majority of these services were not reasonable and necessary for the beneficiary’s health condition or lacked sufficient documentation. OIG will determine whether Medicare payments for therapy services were made in accordance with applicable Medicare requirements.
Status: OAS; W-00-05-35119; various reviews; expected issue date: FY 2008; work in progress
3. Skilled Nursing Facility Consolidated Billing:
OIG will review Medicare Part B claims submitted by suppliers for services provided to beneficiaries during Part A Medicare-covered SNF stays. Prior work has identified significant improper claims submission and reimbursement in this area, and the OIG is continuing their work to identify additional overpayments.
Status: OAS; W-00-06-35185; various reviews; expected issue date: FY 2008; work in progress
4. Oversight of Medicare Skilled Nursing Facility Cost Reports:
OIG will review a sample of nursing facility cost reports. CMS has issued guidelines governing the reporting of cost data in its “Provider Reimbursement Manual.” They will determine the extent to which CMS is monitoring Medicare nursing facility cost reports to ensure compliance with established requirements and whether submitted cost reports meet those requirements.
Status: OEI; 00-00-00000; expected issue date: FY 2008; new start
5. Provider Bad Debts:
OIG will review Medicare bad debts claimed by SNFs to determine whether they were reimbursable. They will determine whether the bad debt payments were appropriate under Medicare regulations and whether recoveries of prior year writeoffs were properly used to reduce the cost of beneficiary services for the period in which the recoveries were made.
Status: OAS; W-00-08-35404; expected issue date: FY 2008; new start
6. Part B Services in Nursing Homes - An Overview:
OIG will review the extent of Part B services provided to nursing home residents whose stays are not paid for under Medicare's Part A SNF benefit. This review will determine the extent of Part B services provided to nursing home residents during 2006 and assess patterns of billing among nursing homes and providers. OIG also plans a number of in-depth reviews on specific Part B services, such as DME and enteral nutrition therapy.
Status: OEI; 06-07-00580; expected issue date: FY 2008; work in progress
7. Part B Services in Nursing Homes -Durable Medical Equipment:
OIG will review Medicare Part B DME payments allowed for items or supplies provided to beneficiaries in nursing homes. A previous OIG report found that $210 million was potentially inappropriately paid for DME for beneficiaries residing in nursing homes. OIG will review 2006 Medicare claims data to determine the appropriateness of Medicare Part B DME services allowed for beneficiaries during nursing home stays not covered by Medicare Part A, and also assess the efforts of Medicare suppliers and contractors to detect and prevent inappropriate Part B DME payments.
Status: OEI; 06-07-00100; expected issue date: FY 2008; work in progress
8. Part B Services in Nursing Homes - Enteral Nutrition Therapy:
OIG will review Part B ENT, commonly called tube feeding, to determine the appropriateness of payments for associated services. This review will specifically assess the medical necessity, adequacy of documentation, and coding accuracy of claims submitted for Medicare beneficiaries during a nursing home stay that is not covered under the Part A SNF benefit. (ENT provided during a Part A SNF stay is the subject of another OIG review focusing on consolidated billing for SNFs and will address ENT provided during a Part A SNF stay). OIG will assess the appropriateness of payments for claims for ENT.
Status: OEI; 06-07-00090; expected issue date: FY 2008; work in progress
9. Payments for Drugs Under Medicare Part D During Part A Skilled Nursing Stays:
OIG will review the extent to which payments are being made by Medicare Part D for drugs already paid for by Medicare Part A. OIG will determine the extent to which drugs are being paid for under Part D while Medicare beneficiaries are covered under Part A SNF stays and identify the patterns, if any, associated with these drugs.
Status: OEI; 02-07-00230; expected issue date: FY 2008; work in progress
10. Implementation of Medicare Part D in Nursing Facilities:
OIG will review the implementation of Medicare Part D for dual-eligible residents in a sample of nursing homes. This review will assess whether dual-eligible residents are receiving medically necessary drugs and the factors contributing to the drugs they receive. OIG will also identify concerns of nursing home and long term care pharmacy staff regarding the implementation of Part D in nursing homes.
Status: OEI; 02-06-00190; expected issue date: FY 2008; work in progress
11. Part B Services in Nursing Homes: Mental Health Needs and Psychotherapy Services:
OIG will review Medicare Part B payments for psychotherapy services provided to nursing home residents during noncovered Part A stays. A previous OIG review found that approximately 31 percent of outpatient claims for Part B mental health services allowed by Medicare did not meet coverage guidelines, resulting in $185 million in inappropriate payments. OIG will determine the medical necessity of services, appropriateness of coding, and adequacy of nursing home documentation.
Status: OEI; 06-06-00580; expected issue date: FY 2008; work in progress
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