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On his first visit to the live Internet radio broadcast of RACmonitor, Larry Goldberg, principal deputy inspector general for the Department of Health and Human Services Office of Inspector General (OIG), provided insights into two areas of growing concern for the federal government: Medicaid’s personal care services (PCS) program and Medicare’s improper payments to skilled nursing facilities (SNFs).

In explaining the issues surrounding the PCS program, Goldberg introduced the new OIG Portfolio and described why Medicaid PCS was the first area to be included in it.

The purpose of the OIG Portfolio is to synthesize the results of all of its prior audits, evaluations, and investigations. It also identifies trends in payment, compliance, oversight, or fraud vulnerabilities and offers comprehensive recommendations in areas that require priority attention and action. For its first portfolio, the OIG chose Medicaid PCS (that is, services provided in a patient’s home, such as bathing, light housework, dressing, and meal preparation) for the following reasons.

Oversight Needed for Medicaid PCS

Since 2006, the OIG has conducted numerous fraud investigations and issued 23 reports on the topic of PCS. Goldberg reported that in 2011, the Medicaid program spent almost $13 billion for these services, which represented a 35 percent increase in payments since 2005. In one state, the payment error rate hit 40 percent and submission of fraudulent claims increased. He calls these findings a “top concern for OIG,” and explains the problem as follows.

The OIG found that Medicaid paid claims for care attendants who didn’t meet the basic qualification standards and also identified documentation indicating that care was given in nursing home or institution instead of in the home, which is the purpose of the benefit. OIG recommended that the Centers for Medicare & Medicaid Services (CMS) require that:

  • All individuals who provide these services meet minimum qualification standards, register with the state, and obtain their own individual identification numbers
  • Submitted claims include not only the date when services were performed but also the type of services provided

“At bottom, we need to be sure Medicaid is paying for and patients are receiving the most appropriate care possible,” said Goldberg. To improve billing problems, CMS should specify how:

  • Claims should be documented
  • Patient needs should be assessed
  • Patient plans of care should be developed
  • Attendance should be supervised.

CMS also should issue guidance to states about prepayment controls because, as he noted, “It’s much more difficult to recover money after the claims have been paid.”

SNFs: Another High-Risk Area

In 2012 alone, Medicaid paid over $32 billion for skilled nursing facility, involving more than 2 million patients. In a recently issued study, referenced in a RACmonitor.com article, OIG found that 25 percent of the bills submitted to Medicare contained errors, resulting in $1.5 billion in inappropriate Medicare payments. Most of the errors involved up-coding—billing for a higher level of service than the patient needed or than was actually provided.

Goldberg explained that, oftentimes, facilities billed for physical, speech, or occupational therapy that the patient didn’t receive or that weren’t reasonable or necessary for patient’s condition. Facilities also misreported information on patient assessments for nearly half of all claims—assessments that form the basis of how Medicare issues payment and how providers develop patient-care plans. As he noted, “Inaccurate assessments affect quality of care.”

The OIG recommended that CMS change how it pays for therapy, thus reducing incentives for facilities to bill for more services than needed, and how it reviews claims. In addition, CMS should use its fraud-prevention system, which uses predictive-data analytics that will help identify facilities that are overbilling.

Goldberg stated that the OIG’s investigations into SNF billing aren’t over and auditors will continue to be on the alert for problems. It also will issue a report in the spring of 2013 addressing quality care for SNF patients. For example, questions addressed will include: Do patient care plans include all of the problems identified? Did the facility provide services for the problems identified? Are facilities following discharge-planning requirements? If a high number of facilities are not incompliance, OIG plans to will quantify the resulting improper payments.

For More Information

Be sure to review the OIG’s website at www.oig.hhs.gov, and sign up email updates, twitter, podcasts; watch videos; and more. And you can listen to Monitor Monday’s broadcast with Mr. Goldberg.

For the OIG’s report on SNF overpayments highlighted above, go to https://oig.hhs.gov/oei/reports/oei-02-09-00200.asp. The PCS report can be viewed or downloaded at https://oig.hhs.gov/reports-and-publications/portfolio/index.asp.

Download the PDF – http://racmonitor.com/downloads/oei-02-10-00340.pdf

About the Author

Janis Oppelt is editor for MedLearn Publishing, Panacea Healthcare Solutions, Inc., St. Paul, MN.

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Janis Oppelt

Janis Oppelt was the former editorial director for MedLearn Publishing.

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