The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) Work Plan for fiscal year (FY) 2017 summarizes new and ongoing reviews and activities that OIG plans to pursue with respect to HHS programs and operations during the current fiscal year and beyond. Work planning is an ongoing and evolving process, and the Work Plan is updated throughout the year. This edition of the Work Plan describes OIG audits and evaluations that are underway or planned, and certain legal and investigative initiatives that are continuing. It also notes items that have been completed, postponed, or canceled and includes new items that have been started or planned since April 2016.
In the plan are a number of new and revised projects for the post-acute and long-term care setting including:
Medicare Payments for Transitional Care Management
Transitional Care Management (TCM) includes services provided to a patient whose medical and/or psychosocial problems require moderate or high-complexity medical decision-making during transitions in care from an inpatient hospital setting (including acute hospital, rehabilitation hospital, long-term acute care hospital), partial hospital, observation status in a hospital, or skilled nursing facility/nursing facility, to the patient’s community setting (home, domicile, rest home, or assisted living). Beginning January 1, 2013, Medicare covered TCM services and paid for them under the Medicare Physician Fee Schedule. Medicare-covered services, including chronic care management, end-stage renal disease, and prolonged services without direct patient contact, cannot be billed during the same service period as TCM. OIG will determine whether payments for TCM services were in accordance with Medicare requirements.
Medicare Payments for Chronic Care Management
Chronic Care Management (CCM) is defined as the non-face-to-face services provided to Medicare beneficiaries who have multiple (two or more), significant chronic conditions (Alzheimer’s disease, arthritis, cancer, diabetes, etc.) that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. These significant chronic conditions are expected to last at least 12 months or until the death of the patient. CCM cannot be billed during the same service period as transitional care management, home health care supervision/hospice care, or certain end-stage renal disease services. Beginning January 1, 2015, Medicare paid separately for CCM under the Medicare Physician Fee Schedule and under the American Medical Association Current Procedural Terminology. OIG will determine whether payments for CCM services were in accordance with Medicare requirements.
Nursing Home Complaint Investigation Data Brief
All nursing home complaints categorized as immediate jeopardy and actual harm must be investigated within a 2- and 10-day timeframe, respectively. A 2006 OIG report found that State agencies did not investigate some of the most serious complaints within these required timeframes. OIG will determine to what extent State agencies investigate the most serious nursing home complaints within the required timeframes. This work will provide an update from our previous review.
Skilled Nursing Facilities- Unreported Incidents of Potential Abuse and Neglect
Ongoing OIG reviews at other settings indicate the potential for unreported instances of abuse and neglect. OIG will assess the incidence of abuse and neglect of Medicare beneficiaries receiving treatment in SNFs and determine whether these incidents were properly reported and investigated in accordance with applicable Federal and State requirements. OIG will also interview State officials to determine if each sampled incident was reported, if required, and whether each reportable incident was investigated and subsequently prosecuted by the State, if appropriate
Potentially Avoidable Hospitalizations of Medicare- and Medicaid –Eligible Nursing Facility Residents
High occurrences of patient transfers from nursing facilities to hospitals for potentially preventable conditions could indicate poor quality of care. Prior OIG work identified a nursing facility with a high rate of Medicaid recipient transfers to hospitals for a urinary tract infection (UTI), a condition that is often preventable and treatable in the nursing facility setting without requiring hospitalization. The audit disclosed that the nursing facility often did not provide UTI prevention and detection services in accordance with its residents’ care plans, increasing the residents’ risk for infection and hospitalization. OIG will review nursing homes with high rates of patient transfers to hospitals for potentially preventable conditions and determine whether the nursing homes provided services to residents in accordance with their care plans (42 CFR § 483.25(d)).
Skilled Nursing Facility Adverse Event Screening Tool
OIG developed the SNF adverse event trigger tool as part of its study, “Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries” (OEI-06-11-00370), released in February 2014. The tool was developed with assistance from clinicians at the Institute for Healthcare Improvement (IHI), which also published the tool for industry use. This product will describe the purpose, use, and benefits of the SNF adverse event trigger tool and the guidance document released by IHI, including the methodology for developing the instrument and the instrument’s use in developing the February 2014 report findings. The product will also describe the contributions of OIG and IHI. The goal of this product is to disseminate practical information about the tool for use by those involved with the skilled nursing industry.
To review the entire OIG plan click here.