Medicare Compliance & Reimbursement

Ignoring these 5 regulatory hot spots could be disastrous.

The spotlight on quality of care in nursing homes just got brighter - and looking the other way would be a huge mistake for skilled nursing facilities.

That's the message that many providers are taking away from the new work plan from the HHS Office of Inspector General, released Oct. 12. The feds continue to focus strongly on nursing home quality, even in the aftermath of the Medicare Prescription Drug Improvement and Modernization Act.

But the feds may not be rushing to action on all fronts - the work plan revisits several stalled long-term care goals from the 2004 plan, notes attorney Marie Infante of Mintz Levin Cohn in Washington. Even so, providers can expect a watchful eye - and action - on a variety of issues. What can providers expect? A tougher survey process, a louder call for compliance with consolidated billing requirements, and the promise of stricter enforcement of sanctions against poor performing nursing homes.

Bottom line: Medicare- and Medicaid-certified facilities need to step up efforts to improve care. Poor performers that don't may be subject to stricter enforcement actions, including denial of payments and civil monetary penalties, suggests Joanne Lax, an attorney with Dykema Gossett in Bloomfield Hills, MI.

SNFs can keep their cool - and their hard-earned cash - by keeping their eyes on the following concerns:

1. Resident assessment. Smart providers will read up on resident assessment shortcomings identified by DAVE, the Data Assessment and Verification project championed by the Centers for Medicare & Medicaid Services. The feds pledge to remain focused on lessons learned during CMS' recent review of facilities' accuracy on the Minimum Data Set (MDS).

Two OIG work plan topics center on resident assessment. The new "Nursing Home Resident Assessment and Care Planning" entry promises a fresh look at the severity of deficiencies related to assessment and care planning. And the revisited call for "Nursing Home Compliance with Minimum Data Set Reporting Requirements" reminds providers that the MDS is "one of the primary mechanisms for addressing residents' quality of care."

Look for: A renewed focus on accuracy of resident assessment and MDS coding, as well as attention to providers' ability to file assessments in a timely manner, suggests Pam Manion, a corporate nurse with Delmar Gardens in Maryland Heights, MO. Pressure from CMS on states where surveyors have been lax will mean a more formidable regulatory burden for providers.

How to prepare: Step up training on resident assessment and MDS coding, including a review of the findings from the latest DAVE bulletin.

To view the bulletin, go to www.cms.hhs.gov/DAVE.asp.

2. Reimbursement. Essentially, CMS seems to be saying "show me the money," suggests Infante. She notes, for example, the work plan's inclusion of the new focus on the use of additional funds provided to skilled nursing facilities. That provision calls for a review of how nursing homes are using funds granted in 2003 through the 3.26 forecast error adjustment in the rates paid to nursing homes for the care of residents in Part A Medicare stays.

Look for: Audits of how federal payments are allocated to care are likely coming down the pike.

How to prepare: Take cost report documentation seriously - and look for results from a survey (unaffiliated with the OIG initiative) by Muse and Associates that asks providers how they've spent the extra funding. Findings will go to Sen. Charles Grassley (R-IA), who last year assured fellow legislators that nursing homes would spend the "correction" funding on direct-care staffing. To take part in the survey, contact Muse and Associates' Steven Heath at sheath@muse-associates.com.
 
3. Specific billing concerns. In particular, auditors will be looking at SNF bills for imaging and laboratory services as well as rehabilitation and infusion therapy services.

Look for: The feds will be conducting medical reviews of documents showing medical necessity. Wording in the work plan suggests that auditors will be on the lookout for fraud as well as inappropriate billing for infusion therapy and rehabilitation.

How to prepare: Document medical necessity carefully, suggests Marilyn Mines of FR&R Healthcare in Deerfield, IL.

4. Residents' rights. A new section in the work plan singles out residents' rights as a hot regulatory concern. "We will assess the extent to which nursing homes' residents and their families are aware of their rights," promises the OIG.

Look for: You will likely be subjected to added scrutiny of residents' rights issues at survey time.

How to prepare: Train staff in residents' rights.

5. Use of psychotropic drugs. Don't grow complacent about this perennial concern, cautions Lax. It may be a perennial, but with a renewed focus generally on pharmaceutical fraud, the OIG is likely to stand by its pledge to monitor the use of such meds.

Look for: Providers will likely see renewed vigilance in the feds' enforcement of existing regulations.

How to prepare: Use drugs according to current clinical practice guidelines, and document medical necessity carefully. For protection against fraud-related concerns, carefully screen employees and take appropriate measures to prevent the misuse of drugs intended for patients.

Check out the new Medlearn Matters article on the topic, "Psychotropic Drug Use in Skilled Nursing Facilities," at www.cms.hhs.gov/medlearn/matters. Search for article number SE0316.

For a copy of the OIG work plan, go to www.oig.hhs.gov/publications/workplan.html#1.