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OIG Work Plan Outlines Risk Areas for SNFs

MacKenzie Kimball, for HealthLeaders Media, October 5, 2009

The Office of Inspector General (OIG) released its fiscal year (FY) 2010 Work Plan October 1, which listed the issues OIG plans to investigate in the coming fiscal year, including a variety of focus areas related specifically to nursing homes.

All nursing homes should be aware of the issues included in the Work Plan and ensure they are complying with the regulations. Otherwise, facilities run the risk of being audited by the OIG.

Some of the nursing home issues included in the FY 2010 Work Plan are:

Part B services: Mental health needs and psychotherapy. OIG plans to review Medicare Part B payments for psychotherapy services provided to nursing home residents during noncovered Medicare Part A skilled nursing facility (SNF) stays. A previous OIG review found that approximately 31% of outpatient claims for Part B mental health services allowed 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.

Medicare requirements for quality of care in SNFs. OIG will assess how SNFs have addressed certain federal requirements related to quality of care. Specifically, OIG will determine the extent to which SNFs:

  • Developed plans of care based on assessments of residents
  • Provided services to residents in accordance with these plans of care
  • Planned for residents' discharges

OIG will also review SNFs' use of the Resident Assessment Instrument (RAI) to develop nursing home residents' plans of care.

Accuracy of SNF resource utilization groups (RUG) coding. OIG will review SNF claims for Medicare reimbursement to determine the accuracy of RUG coding. In 2006, OIG reported that 22% of claims had RUGs associated with higher payment rates than those generated in and supported by patients' medical records.

Nursing home emergency preparedness and evacuations during selected natural disasters. OIG will review nursing homes' emergency plans and emergency preparedness deficiencies cited by state surveyors to determine the sufficiency of the nursing homes' plans and implementation of the plans. In 2006, OIG reported that nursing homes in certain Gulf states had plans that lacked a number of provisions suggested by emergency preparedness experts and that staff did not always follow emergency plans.

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