On June 12, 2019, OIG released two audit reports, A-01-17-00513 and A-01-16-00509, as part of its efforts to improve identification, reporting, and investigation of potential abuse and neglect of Medicare beneficiaries. OIG’s audits were prompted in part by investigations showing “a significant number of Medicare claims submitted for the treatment of injuries related to potential abuse and neglect.” OIG found that incidents of abuse and neglect in skilled nursing facilities (SNFs) were not sufficiently tracked, reported, and investigated, and that Medicare’s diagnosis code data could help point to abuse and neglect. The audit reports follow CMS’s recent release of its five-part nursing home plan focused on improving nursing home quality.
In OIG Report A-01-17-00513, titled, “CMS Could Use Medicare Data to Identify Instances of Potential Abuse or Neglect,” OIG identified nearly 35,000 Medicare inpatient and outpatient claims (totaling approximately $100 million worth of services) from 2015 to 2017 containing one of 17 diagnosis codes that may correlate to abuse or neglect, such as potential sexual abuse or nutritional neglect. Of that group, 100 claims underwent an in-depth review.
OIG found that 94 of the 100 claims evidenced potential abuse or neglect; among them, 61 were likely associated with incidents in the beneficiaries’ home and 16 incidents occurred at others’ homes or in public settings like parks and alleys. From this 100-claim data sample, OIG estimated that 89% of the nearly 35,000 cases had underlying medical records evidencing potential abuse or neglect. OIG further estimated that 8% of those cases may have been perpetrated by a healthcare worker, among other findings.
OIG recommended that CMS “compile a complete list of diagnosis codes that indicate potential physical or sexual abuse and neglect,” “conduct periodic data extracts” of Medicare claims with one of those codes, “inform States that the extracted Medicare claims data are available to help States ensure compliance with their mandatory reporting,” and “assess the sufficiency of existing Federal requirements . . . to report suspected abuse and neglect of Medicare beneficiaries . . . .” CMS disagreed that the recommended claims data would timely assist it with addressing acute problems, but OIG “continue[d] to recommend the use of the Medicare claims data” to thwart abuse and neglect.
In OIG Report A-01-16-00509, titled, “Incidents of Potential Abuse and Neglect at Skilled Nursing Facilities Were Not Always Reported and Investigated,” OIG reviewed a set of claims of Medicare beneficiaries residing in SNFs who had emergency room visits in 2016 that resulted in one of 580 “high-risk” diagnosis codes, and whether the SNFs reported those potential instances of abuse or neglect. The audit also focused on the adequacy of CMS’s reporting and tracking of those potential instances of abuse and neglect.
Specifically, OIG pulled a sample of 256 emergency room (ER) cases from over 37,000 high-risk hospital ER claims for nearly 35,000 Medicare beneficiaries residing in SNFs in eight states in 2016. OIG worked with the State Survey Agencies (SSAs) to review the underlying medical records to determine whether the ER cases were the result of abuse or neglect in the SNF. OIG concluded that approximately one in five of the ER claims were the result of abuse or neglect. OIG also found that the SNFs “failed to report many of these incidents” to SSAs, meaning the SSAs could not conduct immediate onsite investigations. The SSAs themselves also, given the opportunity, “failed to report some findings of substantiated abuse to local law enforcement.” OIG also faulted CMS’s recording and tracking mechanisms for failing to capture all fraud and abuse incidents.
OIG recommended that CMS “take action” to ensure that such incidents are properly identified and reported by improving training for SNF staff and requiring SSAs to track all incidents and subsequent referrals to law enforcement. CMS concurred with these recommendations.
These two audit reports follow CMS’s April 15, 2019 release of a five-part plan to combat nursing home abuse and neglect. While noting that CMS’s approach to nursing home oversight is “constantly evolving,” the plan promises to “strengthen oversight,” “enhance enforcement,” “increase transparency,” “improve quality,” and “put patients over paperwork.” The plan emphasized greater scrutiny of SSAs, which have been inconsistent in their oversight, according to CMS. The plan also sought to increase inspections after-hours and on weekends to spot suspected understaffing and increase enforcement actions on that deficiency. The five-part plan also revamps CMS’s nursing home quality website, Nursing Home Compare, and promises to publish additional data on nursing home quality for public review.
