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The OIG Increases its Oversight of Skilled Nursing Facilities to Include a Review of Care for Dually Eligible Individuals


The U.S. Department of Health and Human Services (DHHS) Office of Inspector General (OIG) recently updated its Work Plan in March 2019 to add an additional topic focusing on nursing facilities that receive Medicare and Medicaid reimbursement. The Work Plan describes new and ongoing OIG audits and evaluations for DHHS programs and operations, including Medicare and Medicaid. The OIG updates its Work Plan throughout the year and the release of an update provides an opportunity for nursing facilities to review their own operations and practices in order to identify areas for compliance improvement.

The OIG conducts investigative activities that involve allegations of fraud, waste and abuse in all of DHHS’s programs. Medicare and Medicaid constitute a significant amount of its work. Areas that the OIG can investigate include billing for services not rendered, provision of medically unnecessary services and misrepresented services, patient harm, and the solicitation and receipt of kickbacks. In addition to performing investigations, the OIG is also involved in facilitating compliance in the health care industry and the exclusion of individuals and entities from participation in Medicare, Medicaid, and other Federal health care programs.

This month, the OIG added a new topic to the Work Plan focusing on post-hospital skilled nursing facility (SNF) care to individuals eligible for Medicare and Medicaid, or dually eligible individuals. Similar to topics added in the past, the OIG noted previous reviews as the basis for the addition. Here, the OIG references previous reviews that showed some nursing facility residents who received Medicaid covered nursing home care were admitted to a hospital, discharged, and then returned to the same facility to receive Medicare covered post-hospital SNF care. The OIG found that nursing facility physicians certified that individuals needed skilled care even though the hospital discharged the individual to home rather than a SNF. This is an area of concern to the Centers for Medicare and Medicaid Services (CMS) because of a belief that nursing facilities have a financial incentive to increase the level of care since Medicare pays more for SNF care than Medicaid pays for nursing home care. 

With this new topic, the OIG will be examining the level of care requirements for post-hospital SNF care provided to dually eligible beneficiaries. Specifically, the OIG will be determining whether:

  • The SNF level of care was certified by a physician or a physician extender;
  • The condition treated at the SNF was a condition for which the individual received inpatient hospital services or was a condition that arose while the individual was receiving care in a SNF for an eligible stay;
  • Daily skilled care was required;
  • The services delivered were reasonable and necessary for the treatment of an illness or injury;
  • The Medicare payments made were improper.

In addition to the review of the SNF claims, the OIG will also determine whether the hospital admissions that are part of the review were unavoidable.

How should a SNF use this information?

These audits and evaluations by the OIG serve as an important reminder that facilities must remain vigilant with their documentation, level of care certifications, and provision of services. The Work Plan provides insight into the areas that could come under scrutiny and ultimately can help guide internal compliance activities for your facility.

With the recent addition to the Work Plan in mind, facilities should review their operations and take the steps necessary to be better prepared to achieve and maintain compliance and provide proper and quality care.

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