• OIG - Nursing Facilities' Employment of Individuals With Criminal Convictions

    Tuesday April 26, 2011

    Our analysis of criminal history records maintained by the Federal Bureau of Investigation (FBI) revealed that 92 percent of nursing facilities employed at least one individual with at least one criminal conviction. Overall, 5 percent of nursing facility employees had at least one criminal conviction.

    Federal regulation prohibits Medicare and Medicaid nursing facilities from employing individuals found guilty of abusing, neglecting, or mistreating residents by a court of law, or who have had a finding entered into the State nurse aide registry concerning abuse, neglect, or mistreatment of residents or misappropriation of their property. Interpretive guidelines from CMS for this regulation state that "[nursing] facilities must be thorough in their investigations of the past histories of individuals they are considering hiring." Despite this guidance, Federal law does not require that nursing facilities conduct FBI or statewide criminal background checks. Although FBI maintained criminal history records provide a comprehensive source of criminal histories, the records do not contain information on whether the victim of a crime was a nursing facility resident and therefore cannot be used by themselves to determine whether a conviction disqualifies an individual from nursing facility employment.

    Most often, criminal convictions were for crimes against property (e.g., burglary, shoplifting, and writing bad checks) and occurred prior to employment. We also found that despite the lack of a Federal requirement for nursing facilities to conduct criminal background checks, most States required, and/or nursing facilities reported conducting, some type of background check.

    In light of the National Background Check Program that the Patient Protection and Affordable Care Act created, we recommended that CMS develop background check procedures. In developing those procedures, CMS should (1) clearly define the employee classifications that are direct patient access employees and (2) work with participating States to develop a list of convictions that disqualify an individual from nursing facility employment under the Federal regulation and timeframes in which each conviction bars the individual from employment.

    In its written comments on the report, CMS agreed with our recommendation. CMS stated that in its solicitation to States for the National Background Check Program, the definition of "direct patient access employee" is broad and outcome based, which in nursing facilities should include all staff. CMS stated that it will work with the States through the National Background Check Program to assist them in developing lists of convictions that disqualify individuals from employment, as well as defining whether any of those conviction types can be assumed to be mitigated because of the passage of time and which convictions should never be considered mitigated or rehabilitated.

    Click here for the full report

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  • OIG- Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents

    Wednesday May 4, 2011

    Report: OEI-07-08-00150


    For the period January 1 through June 30, 2007, we determined using medical record review that 51 percent of Medicare claims for atypical antipsychotic drugs were erroneous, amounting to $116 million.

    A member of Congress requested that OIG evaluate the extent to which elderly nursing home residents receive atypical antipsychotic drugs and the associated cost to Medicare. Specifically, this member expressed concern with atypical antipsychotic drugs prescribed to elderly nursing home residents for off-label conditions (i.e., conditions other than schizophrenia and/or bipolar disorder) and/or in the presence of the condition specified in the Food and Drug Administration's (FDA) boxed warning (i.e., dementia). Medicare requires that drugs be prescribed for "medically accepted indications" for reimbursement. Further, CMS sets standards to ensure that nursing home residents' drug therapy regimens are free from unnecessary drugs.

    We also found that 14 percent of the 2.1 million elderly (i.e., age 65 and older) nursing home residents had at least 1 claim for these drugs. We determined using medical record review that 83 percent of Medicare claims for atypical antipsychotic drugs for elderly nursing home residents were associated with off-label conditions and that 88 percent were associated with the condition specified in the FDA boxed warning. We further determined through medical record review that 22 percent of the atypical antipsychotic drugs associated with the claims were not administered in compliance with CMS standards regarding unnecessary drugs in nursing homes, amounting to $63 million. Nursing homes' failure to comply with these standards may affect their participation in Medicare. However, nursing homes' noncompliance with these standards does not cause Medicare payments for these drugs to be erroneous.

    To ensure that Medicare correctly pays for atypical antipsychotic drugs and that elderly nursing home residents are free from unnecessary drugs, we recommend that CMS (1) facilitate access to information necessary to ensure accurate coverage and reimbursement determinations, (2) assess whether survey and certification processes offer adequate safeguards against unnecessary antipsychotic drug use in nursing homes, (3) explore alternative methods beyond survey and certification processes to promote compliance with Federal standards regarding unnecessary drug use in nursing homes, and (4) take appropriate action regarding the claims associated with erroneous payments identified in our sample.

    In its written comments on the report, CMS shared our concern and that of Congress over whether atypical antipsychotics and other drugs are being appropriately prescribed for elderly nursing home residents. CMS concurred with the second, third, and fourth recommendations; however, CMS did not concur with the first recommendation and expressed several general concerns with the report.

    CMS did not concur with the first recommendation, stating that diagnosis information is not a required data element of pharmacy billing transactions nor is it generally included on prescriptions. OIG recognizes that the industry has not developed a standardized way of collecting diagnosis information for prescription drugs. However, without access to diagnosis information, CMS cannot determine the indications for which drugs were used. For this reason, CMS is unable, absent a medical review, to determine whether claims meet payment requirements.

    Although CMS concurred with the second recommendation, we further recommend that CMS use its authority through the survey and certification processes to hold nursing homes accountable when unnecessary drug use is detected.

    Although CMS concurred with the third recommendation, it did not believe some of the examples of alternative methods to promote compliance provided in the report to be practicable. We suggest that CMS either use its existing authority or seek new statutory authority to prevent payment and hold nursing homes responsible for submitting claims for drugs that are not administered according to CMS's standards regarding unnecessary drug use in nursing homes.

    Click Here for Full Report

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  • OIG- Billing Practices in Skilled Nursing Facilities

    Thursday June 23, 2011

    A summary and suggestions regarding the Office of Inspector General's Report on billing practices in Skilled Nursing Facilities

    In December, 2010, the OIG issued a report on Medicare Part A services provided in the SNF setting. This summary addresses the findings along with suggestions. 

    In the recent past the OIG has found a number of issues with SNF billing for Part A services. One such report analyzing claims from 2006-2008, found that 26% of claims submitted were not supported by the medical records resulting in over $500 million in potential overpayments. Along with these findings, the Medicare Payment Advisory Commission indicated that SNFs may be improperly billing for therapy in order to obtain additional Medicare payments.


    • SNFs were increasingly billing for higher paying RUGs, even though the beneficiary characteristics remained almost the same.
    • For-profit SNFs were more likely to bill higher paying RUGs than nonprofit and government SNFs.
    • Some  SNFs had questionable billing in 2008, frequently billing for higher RUGs and having longer length of stays (LOS) than other SNFs.

    OIG Conclusions

    These findings raised concerns about the potentially inappropriate use of higher paying RUGs, especially the Ultra High category and deduced that the payment system offered incentives to place beneficiaries into these categories when that level of care was not needed. The report acknowledged that a new payment system was being introduced but felt that more needed to questionable billing practices.


    If you are not sure if you are up to date with the Medicare guidelines and documentation standards or whether your SNF would pass a RAC Audit or other OIG or CMS review, then consider looking for related regulations, guidelines, MDS analysis on LTC Provider University's website.

    Click here for a copy of the Full Report

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  • Reporting Reasonable Suspicion of a Crime in a Long-Term: Section 1150B of the Social Security Act

    Friday June 17, 2011

    Section 1150B of the Social Security Act (the Act), as established by section 6703(b)(3) of the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act), requires specific individuals in applicable long-term care facilities to report any reasonable suspicion of crimes committed against a resident of that facility. Reports must be submitted to at least one law enforcement agency of jurisdiction and the state survey agency (in fulfillment of the statutory directive to report to the Secretary).

    This memorandum discusses applicability of this provision to the following Medicare and Medicaid participating long-term care provider types that are collectively referred to as "facilities" or "LTC facilities" in this memorandum:

    • Nursing facilities (NFs),
    • Skilled nursing facilities (SNFs),
    • Hospices that provide services in LTC facilities, and
    • Intermediate Care Facilities for the Mentally Retarded (ICFs/MR).

    Click here for the report:

    June 17, 2011 Reporting Reasonable Suspicion of a Crime

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  • CMS Memorandum

    Friday July 1, 2011

    July 1, 2011 Changes to MDS 3.0 Assessment Modification & Formatting Policies & Nursing Home Compare website.

    The purpose of this CMS memorandum is to describe changes that the Centers for Medicare & Medicaid Services (CMS) has made to the MDS 3.0 assessment modification and formatting policies, as well as changes to the Nursing Home Compare website as a result of MDS 3.0 implementation.

    Click here for full report

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  • The Centers for Medicare and Medicaid Services has announced it will cut Medicare payments...

    Monday August 29, 2011

    The Centers for Medicare and Medicaid Services has announced it will cut Medicare payments to skilled nursing facilities by $3.9 billion next year to recover overpayments it made to companies that inflated their costs. CMS says its newly recalibrated classification system, known as "Resource Utilization Groups Version 4," or RUG-IV, will eliminate skilled nursing facilities' ability to bill for a higher level of care than they actually provide to patients. According to a July 29 statement ...


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  • New Quality Indicator Survey (QIS) Documents

    Thursday August 11, 2011

    Click on the link below to download the QIS documents:

    QIS Brochure April 2011

    QIS Checklist Final July 2011

    QIS Implementation Map April 2011

    QIS Memo Checklist Changes July 2011

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  • Same Sex Partners and Medicaid Liens, Transfers of Assets, and Estate Recovery โ€“ June

    Monday August 8, 2011

    The purpose of this letter is  to ensure that States are informed of the existing options and flexibilities regarding the application of Medicaid liens, transfer of assets, and estate recovery. Specifically, this letter is intended to advise States of existing choices and options regarding spousal and domestic partner protections related to liens, transfer of assets, and estate recovery.

    Same Sex Partners MCD Liens Transfers Estate Rec 06 11

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  • Government Report: Report Examines High Cost of Medicare Hospice in Nursing Homes

    Friday August 5, 2011
    A federal audit of Medicare hospice spending for nursing home residents has revealed that spending has jumped nearly 70 percent since 2005, as some for- profit hospices gained higher enrollment and reimbursement rates at long-term- care facilities. The Office of the Inspector General issued recommendations that the Centers for Medicare and Medicaid Services reduce Medicaid payments for hospice care provided in nursing facilities and closely monitor hospice agencies.
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  • Potential Risk Factors Regarding Mechanical Lifts & Slings

    Wednesday August 3, 2011
    Due to a recent event and in an effort to keep our customers informed of risk management issues, we wanted to communicate potential risk factors regarding mechanical lifts and slings.  There are numerous brands of lifts (Hoyer, Invacare, Reliant, EZ-Access, etc.) There are also numerous brands of slings and in most cases, each sling will contain a warning label that states to utilize the sling only with the same brand of lift.  Therefore, please look at your lift program to determine if the appropriate slings are being utilized with the appropriate lifts.  (Note:  Some distributers may sell some slings as universal slings but the warning labels may still have a disclaimer to only utilize with the same brand of lift.)  Also, each lift manufacturer may have their own fit guide to determine how to measure residents for the appropriate size of sling.  Therefore, if your facility has several different brands of lifts then your staff may have to be knowledgeable of the different fit guides to determine the appropriate size of sling.  Also, your staff should be knowledgeable on guidelines to determine what type of sling should be utilized for the resident, i.e. bathing, transfers, etc.  Will your staff be able to answer questions on how to measure residents for the appropriate fit of a sling for each brand?  Will your staff be able to communicate how they assess a resident to determine which type sling is appropriate for the resident?  How will your facility be able to show how you communicate to your staff the correct size sling and type of sling for each resident?
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  • Arbitration News

    Tuesday August 2, 2011
    Only the resident signed the arbitration provisions contained in the admission agreement. Suit was filed before her death and later amended to include wrongful death. Although currently on appeal before the 11th circuit, the trial court ruled that a personal representative of a resident's estate cannot be compelled to arbitration. They opined that Alabama courts have consistently held that wrongful death claims do not belong to a decedent (Ala. Code ยง 6-5-462). As such, her wrongful death claim belongs to the person representative because as a survival action, the claim would have belonged to the decedent through her estate. The outcome is currently pending on appeal but may have far reaching results. Stay tuned.
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  • Overhaul of Nursing Home Compare website is complete

    Tuesday August 2, 2011

    The redesign of the federal Nursing Home Compare website, which lets consumers file complaints more easily and compare facilities based on quality measures, is complete.


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  • Wilson v. State Farm: One Small Victory for Primary Payers in the MSP Arena

    Tuesday August 2, 2011
    A federal court in the Western District of Kentucky recently provided much awaited clarification on one of many troubling dilemmas faced by defendants, insurers and their  attorneys who are working to adhere to the requirements of Medicare Secondary Payer ("MSP") law.  Despite the challenges associated with complying with MSP law, all of those involved in the settlement of a claim that involves personal injury damages must be diligent to avoid the post-settlement potential for liability to the Centers for Medicare & Medicaid Services ("CMS").
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  • Government Report: Report Examines High Cost of Medicare Hospice in Nursing Homes

    Tuesday August 2, 2011
    A federal audit of Medicare hospice spending for nursing home residents has  revealed that spending has jumped nearly 70 percent since 2005, as some for- profit hospices gained higher enrollment and reimbursement rates at long-term-care facilities. The Office of the Inspector General issued recommendations that  the Centers for Medicare and Medicaid Services reduce Medicaid payments for hospice care provided in nursing facilities and closely monitor hospice agencies.
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  • Rehab facilities see reimbursement increase tied to quality measures

    Tuesday August 2, 2011

    Inpatient rehab facilities will see a 2.2% payment rate increase under the IRF Prospective Payment System in fiscal year 2012. The system will also establish a new quality reporting system authorized by the Affordable Care Act.

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  • Provider shares take a hit on news of CMS reimbursement

    Tuesday August 2, 2011
    Shares of major skilled nursing facility operator stocks took a nosedive Monday morning following Friday's announcement that the Centers for Medicare & Medicaid Services are cutting Medicare reimbursements to SNFs by 11.1%, starting Oct. 1. Operators Sun Healthcare, Skilled Healthcare and Kindred Healthcare lost more than a quarter of their market value on Monday, according to published reports.
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  • Nursing Home Hospitalization Influenced by Payer Status -from thirdage.com

    Wednesday October 19, 2011

    Article from Thirdage.com- by Caitlin Bronson


    A nursing home often decides whether or not to send an ill resident to the hospital or treat them on-site depending on their insurance status, a new study from the University of Rochester Medical Center found. As reported by ScienceDaily, residents enrolled in Medicaid are 27 percent more likely to be taken to the hospital than residents with private insurance.

    And that often mean higher health care costs and poorer outcomes, said lead author Shubing Cai of Brown University.

    "Nursing homes, in many instances, have discretion in whether to keep a patient in the facility and expend additional resources, or transfer the resident to the hospital," Cai said. "While we know that nursing homes tend to provide similar quality of care to all residents, hospitalization decisions are often different from the decisions involved in the provision of daily care and have a significant impact on the long-term health of residents."

    According to the same publication, hospitalization of elderly patients is often linked with poor outcomes leading to further physical and psychological decline. Patients are more vulnerable to infections while in the hospital, experience a disruption in care and have been show to decline more quickly in functional status and become more confused.

    The study authors recommend aligning incentives with Medicare and Medicaid, so that nursing homes are paid based on quality measures, including hospitalization rates.

    ScienceDaily noted that Medicaid often reimburses nursing homes at a lower rate for treatment than does private pay insurance, and often below the necessary cost to provide onsite intensive care. That means nursing homes have a strong financial incentive to send ill residents on Medicaid to the hospital, where they know the cost will be taken care of by Medicare.

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