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OIG WORK PLAN: What Nursing Homes Can Expect in 2015


Each year the Office of Inspector General (“OIG”) of the Department of Health & Human Services releases its Work Plan for the coming year.  The Work Plan outlines the OIG’s current areas of focus and its stated objectives, providing a unique alert to those in the healthcare industry and affording them the opportunity to evaluate their areas of risk and determine how to best prioritize their compliance and audit efforts for the months ahead.

As it relates to nursing homes, this year’s Work Plan is, in large part, a continuation of recent Work Plans.  OIG will continue to dedicate the bulk of its attention to two primary areas: (i) billing practices and (ii) quality of care issues.  Regarding billing practices, the OIG will focus its on identifying questionable billing patterns for Part B services in specified contexts and examining and describing variations in certain nursing home Part A billings.[1]  And OIG’s involvement in and adjudication of quality of care issues is further established by its continued examination of hospitalizations of nursing home residents—and the extent to which such occurrences may have been preventable,[2] as well as its new commitment to review emergency transfers from nursing homes to hospitals as a possible indication of substandard care.

In addition, the 2015 Work Plan focuses on the operation and functions of benefit integrity contractors – including ZPICs and PSCs – introducing a review and report that the OIG will conduct relating to the level of benefit integrity activity performed by these contractors in 2012 and 2013.

Below are portions on the OIG Work Plan that are particularly relevant to our clients.

Quality of Care

Hospitalizations of Nursing Home Residents for Manageable and Preventable Conditions:  OIG will determine 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.

Medicaid Beneficiary Transfers from Group Homes and Nursing Facilities to Hospital Emergency Rooms OIG will review the rate of and reasons for transfer from group homes or nursing facilities to hospital emergency departments. High occurrences of emergency transfers could indicate poor quality.[3]

State Agency Verification of Deficiency Corrections:  OIG will determine whether State survey agencies verified correction plans for deficiencies identified during nursing home recertification surveys.[4]

Program for National Background Checks for Long-Term-Care Employees:  OIG will review the procedures implemented by participating States for long-term-care facilities or providers to conduct background checks on prospective employees and providers who would have direct access to patients and determine the costs of conducting background checks.  OIG will determine the outcomes of the States’ programs and determine whether the programs led to any unintended consequences.[5]


Medicare Part A Billing By Skilled Nursing Facilities:  OIG will describe SNF billing practices in selected years and will describe variation in billing among SNFs in those years.[6]

Questionable Billing Patterns for Part B Services During Nursing Home Stays:  OIG will identify questionable billing patterns associated with nursing homes and Medicare providers for Part B services provided to nursing home residents during stays not paid under Part A (for example, stays during which benefits are exhausted or the 3-day prior-inpatient-stay requirement is not met).  A series of studies will examine several broad categories of services, such as foot care.

For assistance in analyzing this information and implementing an effective compliance program, please contact Rytes Company at (888) 99-RYTES or

[1] The Work Plan cites prior OIG work that found that SNFs increasingly billed for the highest level of therapy even though beneficiary characteristics remained largely unchanged, as well as OIG findings that SNFs billed one-quarter of all 2009 claims in error, resulting in $1.5 billion in inappropriate Medicare payments.

[2] In a video entitled OIG Outlook 2014, in which OIG senior executives discuss, among other things, OIG’s top priorities for 2014 and the OIG Work Plan, the Principal Deputy Inspector General, Joanne Chiedi, asserted: “A key focus of our planned work is on the quality of care in nursing homes and how often beneficiaries are harmed during their stay in nursing homes.”

[3] The Work Plan cites congressional interest in this area.

[4] In the State Operations Manual, cited in the Work Plan, CMS requires State survey agencies to verify the correction of identified deficiencies through onsite reviews or by obtaining other evidence of correction.

[5] This program was instituted pursuant to the Patient Protection and Affordable Care Act of 2010 § 6401.

[6] The Work Plan highlights the “substantial changes” CMS has made to how SNFs bill for services for Medicare Part A stays.