Corporate Compliance and the 2015 OIG Work Plan for Nursing Homes

Angie SzumlinskiUncategorized

The Kitch Firm recently had a client that was subject to an investigative subpoena from the Office of Inspector General (OIG) which was looking into MDS/therapy/billing irregularities.  That client said, “I wish there was a service that would tell us what the OIG was going to be looking for so we could be prepared.”  That ability to “foresee the future” has and continues to be available to some extent by reviewing the annual OIG Work Plan.  For example, in 2013 the OIG was looking at “Oversight of the Minimum Data Set Submitted by Long-Term-Care Facilities,” and in 2012 the OIG was looking at “Medicare Part A Payments to Skilled Nursing Facilities.”  In 2012 the OIG stated, “We will review the extent to which payments to SNFs meet Medicare coverage requirements.  We will conduct a medical review to determine whether claims were medically necessary, sufficiently documented, and coded correctly during calendar year (CY) 2009… In a prior report, OIG found that 26 percent of claims had RUGs that were not supported by patients' medical records.  The percentage represented $542 million in potential overpayments for FY 2002.”

The Kitch Firm has historically advised its clients to incorporate the OIG Work Plan each year into their Corporate Compliance Plans.  The Work Plan is a facility's complimentary vision into the future courtesy of the OIG.  A facility is in a much better position to negotiate if it has self-identified a problem through its own Corporate Compliance audit process and voluntarily disclosed/refunded potential overpayments than if the OIG finds the problem.

The OIG recently published its 2015 Work Plan which identifies the areas the OIG believes may be vulnerable to potential fraud and abuse.  The Kitch Firm recommends that nursing facilities use this Work Plan as a means of anticipating risk areas and focusing compliance efforts.  Some of the areas are repeats from previous years, so if your facility has not started looking at those areas, there is no better time than now to work these into your Compliance Program.  The specific areas the OIG will be reviewing include:

Medicare Part A Billing by Skilled Nursing Facilities

This is a repeat concern.  Historical audits have shown fraud and waste trends in skilled nursing facilities.  In efforts to reduce this, the OIG will continue to review and monitor skilled nursing facilities billing practices as well as variations in billing within selected years.  A facility should review the audits it is conducting on claims prior to billing for medical necessity, documentation, and coding accuracy.

Questionable Billing Patterns for Part B Services During Nursing Home Stays

This is also a repeat concern.  The OIG will continue to monitor Part B billing for abuse during non-Part A stays by identifying questionable billing patterns associated with nursing homes and Medicare providers.  The OIG will, as noted in the 2014 FY Work Plan, create a series of studies that will examine several broad categories of services in nursing homes.

State Agency Verification of Deficiency Corrections

Not only is it federally required for nursing homes to submit corrected deficiencies to its state survey agency or Centers for Medicare & Medicaid Services (CMS), state survey agencies are required by CMS to verify the correction plan of identified deficiencies.  As previous reviews have shown that this is not always followed, the OIG will determine that the state survey agencies are verifying the correction plans during nursing home recertification surveys.

Program for National Background Checks for Long-Term-Care Employees

Section 6201 of the Patient Protection and Affordable Care Act (ACA) requires the Secretary of Health and Human Services to carry out a nationwide program for states to conduct national and state background checks for prospective direct patient access employees of nursing facilities and other long term care providers.  The ACA also requires the OIG to submit a report to Congress evaluating the program and thus will continue to mandate and review the procedures implemented by participating states for long term care facilities or providers under this program, seeking out whether the program led to any unintended consequences. 

Hospitalizations of Nursing Home Residents for Manageable and Preventable Conditions

This is a repeat concern of past FY reviews.  The OIG will continue to look at the extent to which Medicare beneficiaries residing in nursing homes are hospitalized as a result of conditions thought to be manageable or preventable in the nursing home setting.

The full text of the OIG Work Plan can by accessed at:

For guidance in bolstering your Corporate Compliance Plan, you can access the Kitch Firm's Long Term Care Compliance website at:

You may also simply contact any member of our Long Term Care Team directly with any questions about how this Work Plan may impact your facility or how you can use this Work Plan to improve your compliance efforts by emailing

This Long Term Care Kitch Report was edited by:

Margaret A. Chamberlain