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.
Criminal background checks for nursing facility employees. OIG will determine the extent to which nursing facilities have employed individuals with criminal convictions.
Oversight of poorly performing nursing homes. OIG will review CMS' and states' use of enforcement measures to determine their impact on improving the quality of care beneficiaries received in poorly performing nursing homes and the performance of these nursing homes. OIG will examine enforcement measures and determine the extent to which CMS and states follow up to ensure that poorly performing nursing homes implement plans of correction.
Part B services in nursing homes. 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 and assess patterns of billing among nursing homes and providers.
Nursing home residents aged 65 or older who received antipsychotic drugs. OIG will review the extent to which nursing home residents aged 65 or older received selected antipsychotic drugs in the absence of conditions approved by the Food and Drug Administration. OIG will also examine Medicare Part D and Part B program reimbursements for selected antipsychotic drugs received by elderly nursing home residents and the extent to which these drugs were prescribed and paid for in accordance with federal regulations.