OIG review finds about 1/3 of all Medicare nursing home stays had inadequate care, care planning or discharge planning

As part of the US Department of Health and Human Services Office of Inspector General's current focus on nursing facilities, the OIG recently released a report entitled: Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements.

From the OIG summary:

Skilled nursing facilities (SNF) are required to develop a care plan for each beneficiary and provide services in accordance with the care plan, as well as to plan for each beneficiary's discharge. These requirements are essential to ensuring that beneficiaries receive appropriate care and safely transition from one care setting to another. Several OIG studies and investigations found that SNFs had deficiencies in quality of care, did not develop appropriate care plans, and failed to provide adequate care to beneficiaries. In fiscal year 2012, Medicare paid $32.2 billion for SNF services. This study is part of a larger body of work about SNF payments and quality of care.

…

For 37 percent of stays, SNFs did not develop care plans that met requirements or did not provide services in accordance with care plans. For 31 percent of stays, SNFs did not meet discharge planning requirements. Medicare paid approximately $5.1 billion for stays in which SNFs did not meet these quality-of-care requirements. Additionally, reviewers found examples of poor quality care related to wound care, medication management, and therapy. These findings raise concerns about what Medicare is paying for. They also demonstrate that SNF oversight needs to be strengthened to ensure that SNFs perform appropriate care planning and discharge planning.

(Emphasis added.)

The OIG found, and CMS agreed, that CMS administrative enforcement efforts need to be beefed up on care planning and discharge planning, and that payment for services needed to be more closely tied to quality of services.

The negative findings implicate about 1/3 of skilled nursing facility stays, and over 15% of Medicare payment for skilled nursing facility stays.

In other arenas where health care providers are found to be out of compliance with Medicare conditions of participation, the Department of Justice tends to initiate actions under the False Claims Act to recover Medicare payments. (One example that leaps to mind involves the physician supervision requirements for diagnostic imaging under the OPPS rule.) Clearly, recoupment of $5.1 billion per year would be disastrous for the nursing facility sector, and since the OIG's recommendations included a mandate to clarify the regulations it is an unlikely result of this report. However, nursing facility operators should take note of this report and begin to address these areas of concern sooner rather than later.

The current report comes on the heels of a report issued late last year highlighting Medicare billing errors by nursing facilities that resulted in overpayments of $1.5 billion in 2009.  CMS committed to take appropriate action following receipt of that report, which could include recoupment of overpayments.

The OIG is currently looking at adverse events in skilled nursing facilities, which will be the subject of an upcoming report.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting