SNF Care/E/M Code Review Included in OIG Work Plan

November 20, 2015
Health Policy

The Office of Inspector General for Health and Human Services (OIG) recently issued its 2016 Work Plan, which sets the agenda for its auditing and investigation in the year ahead. The broad mandate of the OIG is to eliminate fraud, waste and abuse. The work plan describes more than 100 initiatives, 43 of which are new, for the upcoming year. The plan focuses on a variety of different health care aspects including nursing homes, home health agencies, pharmacies and hospitals.

In the past, the OIG has had success with recovering Medicare payments for therapy in nursing homes. Now the OIG is starting a new focus on the documentation requirements specified in 42 CFR Section 483.20 to insure that SNF care is “reasonable and necessary.” Such documentation includes 1) a physician order at the time of admission for the resident’s immediate care 2) a comprehensive assessment and 3) a comprehensive plan of care prepared by an interdisciplinary team that includes the attending physician, a registered nurse, and other appropriate staff.

The OIG will also report on the implementation status and early results for the National Background Check program for long-term-care employees from the first four years of the program.

Another new initiative for 2016 will be the OIG review on the use of the general inpatient care level for the Medicare hospice benefit. “We will assess the appropriateness of hospices’ general inpatient care claims and the continent of election statement for hospice beneficiaries who receive general in patient care. We will also review hospice medical records to address concerns that this level of hospice care is being billed when that level of service is not medically necessary. We will review beneficiaries’ plans of care and determine whether they meet key requirements.”

The OIG will also review whether Medicare payments to physicians for prolonged evaluation and management (E/M) services were reasonable and made in accordance with Medicare requirements.

To review the entire report, click here.