From: HHS Office of Inspector General <donotreply@subscriptions.hhs.gov>
Date: Tue, Jun 10, 2014 at 6:55 AM
Subject: OIG posts 2 reports, related podcast, CIA list update and news about enforcement actions - 6/10
To: iammejtm@gmail.com
Good morning from Washington, DC. Today OIG posts 2 reports, a related podcast, updates the CIA list and provides news about enforcement actions. As always, you can use the links provided to go directly to the new material.
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CMS's Reliance on California's Licensing Surveys of Nursing Homes Could Not Ensure the Quality of Care Provided to Medicare and Medicaid Beneficiaries (A-09-12-02037) http://go.usa.gov/8eE4
In California, the Department of Public Health, Licensing and Certification Division (State agency), must perform licensing surveys of nursing homes every 2 years to determine whether they meet the licensing requirements. Our review examined whether CMS's reliance on the State agency's licensing surveys of nursing homes ensured quality of care and adequate protection for beneficiaries. We found that nursing homes did not always meet certain State requirements for employee health examinations and optional service units. The licensing surveys did not always identify these issues; therefore, CMS's reliance on these surveys could not ensure quality of care and that adequate protection was provided to Medicare and Medicaid beneficiaries. The nursing homes and the State agency could not be sure that nursing home employees were free of any health conditions that might have created a hazard for Medicare and Medicaid beneficiaries. Further, they could not always demonstrate that optional service units, which provided specific types of care, such as physical therapy, at the nursing homes met State requirements for adequate policies and procedures, staff, equipment, and space.
To ensure quality of care and the adequacy of the protection provided to Medicare and Medicaid beneficiaries in nursing homes, we recommended that CMS work with the State agency to ensure that:
(1) Nursing homes implement and follow adequate policies and procedures for employee health examinations and request approval for optional service units,
(2) The State agency conducts all required licensing surveys and reviews employee health examination records during those surveys, and
(3) The State agency improves licensing survey procedures for reviewing employee health examination records and the three required components and determining whether optional service units operated by the nursing homes are approved and optional services are listed on the licenses.
CMS concurred with all of our recommendations and provided information on actions that it planned to take to address our recommendations.
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Podcast: California's Licensing Surveys of Nursing Homes Could Not Ensure the Quality of Care for Beneficiaries http://go.usa.gov/8ePh
Reid Sund, an auditor for the Office of Audit Services, is interviewed by Marc DeGuzman, senior auditor in San Diego.
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The Centers for Medicare & Medicaid Services Paid Medicare Advantage Organizations for Services Provided to Beneficiaries Confined in Mental Health Facilities for Court-Ordered Purposes (A-07-13-06043) http://go.usa.gov/8eEP
During calendar years 2011 and 2012, the Centers for Medicare & Medicaid Services (CMS) made 1,018 payments, totaling $1 million, to Medicare Advantage (MA) organizations on behalf of 207 beneficiaries confined in mental health facilities by court order under a penal code (confined beneficiaries). Had those same persons been enrolled in Medicare Parts A or B, payment would generally not have been made. This occurred because CMS policy permits Medicare payments to be made on behalf of confined beneficiaries enrolled in MA but not on behalf of those enrolled in Part A or Part B.
Federal regulations state that an individual is eligible to enroll in an MA plan if he or she is entitled to Medicare under Part A and enrolled in Part B. For Parts A and B, beneficiaries in custody of penal authorities include confined beneficiaries. Medicare generally does not pay Part A and Part B benefits to incarcerated beneficiaries, but those beneficiaries retain their entitlement to Part A and can retain their enrollment in Part B with the payment of premiums. However, under current policy for the administration of MA, CMS does not consider confined beneficiaries to be incarcerated for the purpose of MA eligibility, regardless of the reason for their confinement. Accordingly, these confined beneficiaries would be eligible for payments under MA.
We recommended that, to be consistent with the relevant provisions of Medicare Part A and Part B, CMS revise its MA guidelines to prohibit MA payments made on behalf of beneficiaries who have been confined in mental health facilities by court order under a penal code, which could have resulted in cost savings totaling $1 million for the 2-year period we reviewed. CMS did not concur with our recommendation, but stated that it recently proposed regulatory changes that will prohibit new or continued enrollment of incarcerated beneficiaries in managed care. After reviewing CMS's comments, we note that CMS's proposed change to the definition of "service area" will exclude mental health facilities from facilities in which individuals are incarcerated. This will not serve to exclude from MA coverage individuals held in the custody of penal authorities in mental health facilities. CMS could implement our recommendation by not adopting the proposed change to the definition of "service area" and by defining individuals who are in custody of penal authorities for purposes of MA in the same manner that it defines those individuals for Medicare Parts A and B in Federal regulations and the Medicare Benefit Policy Manual.
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Updated Corporate Integrity Agreement List: 5 CIAs Closed http://go.usa.gov/8ey3
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June 9, 2014; U.S. Attorney; Southern District of Georgia Brunswick Woman Sentenced to 16 Years in Prison for Defrauding Medicaid of More Than $4 Million http://go.usa.gov/8d3Q
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State Enforcement Actions Updated http://go.usa.gov/8d3e ------------------------------------------------------------------------------
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