The Office of Inspector General (OIG) 2020 workplan includes residents who were receiving Medicaid nursing home care and then were hospitalized. The beneficiary then returned to the same facility and received Medicare covered post-hospital SNF care. In some cases, hospital physicians discharged beneficiaries to home rather than the SNF, yet nursing facility physicians certified that skilled care was needed. Because Medicare pays substantially more for SNF care than Medicaid for nursing home care, nursing home facilities have financial incentives to increase the level of skilled care. This will be the focus of OIG medical review.

 

What will the OIG use to determine if the post-hospital SNF care is dually eligible?

  • the SNF level of care was certified by a physician (e.g., a hospital or SNF physician) or a physician extender (i.e., a nurse practitioner, clinical nurse specialist, or physician assistant);
  • the condition treated at the SNF was a condition for which the beneficiary received inpatient hospital services or a condition that arose while the beneficiary was receiving care in a SNF for a condition for which the beneficiary received inpatient hospital services;
  • daily skilled care was required
  • the services delivered were reasonable and necessary for the treatment of a beneficiary’s illness or injury; and
  • improper Medicare payments were made on the claims we review. We will also determine whether any of the hospital admissions we review were potentially avoidable

 

Prepare for the 2020 OIG Work Plan:

  • Develop policies and procedures related to admission and determination of appropriate level of care and individualize them for your facility.
  • Assure your process for attaining hospital records is timely. This is crucial for not only response to OIG review requests but also for timely PDPM processes including identifying NTA components.
  • Review your facility’s communication for medical review. Did you know HTS partners with a third-party company to complete medical reviews on your behalf? Ask us about our Denials Management Processes today!

 

Bottom Line: There is a very short timeframe for response.

  • Hospital discharge records requested within 7 days and remaining documents within 15 days
  • Specific policies and procedures must be submitted for review as well as facility specific questions related to determining level of care:
    • Policies and procedures related to admission of patients into SNF care
    • Policies and procedures related to determination of appropriate level of care (unskilled/custodial care and skilled care)

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