OIG Report Shows Many Incidents of Potential Abuse or Neglect Unreported in SNFs

The U. S. Department of Health and Human Services (HHS), Office of Inspector General (OIG) recently published an Early Alert report regarding the preliminary results of an ongoing study of potential abuse or neglect in Medicare-certified Skilled Nursing Facilities (SNFs). In the report dated August 24, 2017, the OIG determined that the Centers for Medicare & Medicaid Services (CMS) has inadequate procedures to ensure that incidents of potential abuse or neglect of Medicare beneficiaries residing in SNFs are properly identified and reported. The OIG audit is continuing, but the preliminary results were issued because of the importance of detecting and combating elder abuse. Continue reading

Emerging Compliance Issue: Recent False Claims Act Settlements Based on Improper Billing for Evaluation and Management Services by Physicians

An emerging health care compliance issue for hospitals and health systems is a potential liability under the Federal False Claims Act (FCA) based on billing for evaluation and management (“E & M”) services provided by employed physicians. Although potential liability for billing for E&M services (i.e., office visits) is not new, several recent FCA settlements should remind hospitals and health systems that the government may consider the submission of claims for E&M services under improper codes to result in a false claim. Continue reading

OIG Announces August 2017 Work Plan Updates

The Office of Inspector General (OIG) recently announced on June 15, 2017 that it will be updating the OIG Work Plan on a monthly basis rather than as it previously did once or twice a year. The OIG’s Work Plan includes several projects that the OIG’s Office of Audit Services (OAS) and Office of Evaluation and Inspections (OEI) are currently undertaking or planning to undertake in the future. The topics and focus of these projects are often indicators of potential compliance risk areas for health care providers and other participants in the health care industry. Continue reading

Compliance Risk for Physician Practices in Waiving Patient Copays and Deductibles

The waiver of coinsurance and deductibles owed by patients treated by physicians and other health care providers has come under increased scrutiny recently. Although there are no clear legal prohibitions, commercial health insurers have aggressively pursued out-of-network provides who fail to collect or waive amounts owed by their insureds under different statutory regulations.
Continue reading

Conducting Required Reviews Can Save Your Facility from Embarrassment – and Worse!

Even though we know the old saying “an ounce of prevention is worth a pound of cure,” background checks on on personnel can sometimes fall through the cracks. Here are a few examples of times that make us wish we would have double-checked to be sure they were getting done:

  • A state surveyor is on-site investigating and advises that the allegation of neglect or abuse is against a tech who was convicted for beating up his father a year before he was hired.
  • In employing a favorite PRN nurse who has been around for a couple of years, you learn that she never obtained a license when she moved here from Texas. You realize there may now be returnable overpayments, because she is not appropriately licensed to perform the services in our state.
  • You want to impress your new venture partner, and cringe when they discover in due diligence that your team has not checked the excluded provider or debarred contractor lists in a few years.

Continue reading

CMS Urged to Recoup and Audit EHR Incentive Payments

According to a report released by the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) on June 12, 2017, the Centers for Medicare and Medicaid Services (CMS) overpaid an estimated $729 million in Medicare electronic health record (EHR) incentive payments to participating providers. (The full report is available at https://oig.hhs.gov/oas/reports/region5/51400047.asp). The OIG reviewed whether CMS’ oversight of the Medicare EHR incentive program was sufficient and whether eligible professionals (EPs) nationwide met Medicare incentive payment program requirements and received appropriate incentive payments. Alarmingly, the OIG urged CMS to recoup and audit these incentive payments based on its findings. Participating EPs and hospitals should be cognizant of the ramifications of CMS’ recommendations, including the potential for an audit and recoupment. Continue reading

Final Rule Released to the OIGs Exclusion Authorities

On January 11, 2017, the Office of Inspector General (OIG) of the Department of Health and Human Services released a final rule that incorporates statutory changes, early reinstatement provisions, and policy changes, and clarifies existing regulatory provisions to the OIG’s authorities to exclude persons and entities from participating in Federal health care programs. The Affordable Care Act of 2010 expanded the OIG’s authority to exclude various individuals and entities from participation in Federal health care programs under section 1128 of the Social Security Act (Act). The changes in the final rule to the OIG’s authority were also based on the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), which amended the OIG’s authority to waive certain exclusions under section 1128 of the Act.

A copy of the final rule is available at: http://go.usa.gov/x9Ugu

Written by: Clay J. Countryman

Countryman, Clay headshot