Listening or reading whenever the OIG speaks or publishes something is a good practice for any compliance officer. This includes OIG testimony given to the U.S. Congress. The latest testimony provided by the OIG was to the Finance Committee of the U.S. Senate. The topic was “Promoting Elder Justice: A Call for Reform” and it was provided by Megan H. Tinker, Senior Advisor for Legal Affairs, Office of Counsel to the Inspector General, Office of Inspector General.
Ms. Tinker began by declaring previous OIG work has revealed widespread problems in providing safe, high-quality care to Medicare and Medicaid beneficiaries in many settings and ongoing failures to identify, report, and correct incidents of abuse and neglect when they occur. Her testimony focused on abuse and neglect of Medicare beneficiaries, State Survey Agency response to nursing home deficiencies and complaints, and enforcement actions to address misconduct and grossly substandard care.
The three key take-a-ways from her testimony were:
- CMS, States, and providers should use data to ensure potential abuse and neglect is being identified.
- CMS, States, and providers must ensure potential abuse and neglect is reported to enable oversight and prevention.
- States must ensure deficiencies are corrected.
Much of the value of OIG testimony are the numerous examples of findings from prior OIG audits and investigation. Knowing what they are finding can help other organization’s compliance programs in risk identification and audit planning. For example, OIG’s work on critical incident reporting at group homes showed that group home providers failed to report many critical incidents to the appropriate State agencies. These critical incidents included death, physical/sexual assault, serious injuries, and missing persons. In addition, OIG recently released two reports focused on hospice care. OIG found that from 2012 through 2016, the majority of U.S. hospices that participated in Medicare had one or more deficiencies in the quality of care they provided to their patients. These deficiencies—much like the deficiencies highlighted elsewhere in Ms. Tinker’s testimony—have a human cost on vulnerable beneficiaries and are subject to CMS oversight and enforcement action.
In a June 2019 OIG report, it was demonstrated that Medicare claims can be used to identify incidents of potential abuse or neglect, regardless of where the beneficiary resides. Further, OIG's work showed that many of these incidents were not reported to law enforcement as required. Medicare claims data identified more than 30,000 incidents of potential abuse or neglect. In the OIG review, they identified Medicare claims in all States that contained diagnosis codes indicating the treatment of injuries potentially caused by abuse or neglect of Medicare beneficiaries from January 1, 2015, through June 30, 2017.
All of the diagnosis codes were assigned by the health professional who treated the Medicare beneficiaries. Most of the actual incidents that caused harm occurred in settings other than medical facilities. Only 10 percent were associated with incidents where the injuries occurred in a medical facility, like a nursing home. Healthcare workers were the likely perpetrators of incidents of potential abuse or neglect in about 7 percent of the claims. Approximately 90 percent of the medical records identified by this analysis contained evidence of potential abuse or neglect. This evidence included but was not limited to, witness statements and photographs. OIG estimated that 30,754 claims were supported by medical records that contained evidence of potential abuse or neglect. Providers frequently failed to alert law enforcement to incidents of potential abuse or neglect. Approximately 27 percent of claims were not reported to law enforcement by mandatory reporters even though all States require certain individuals to report suspected abuse, neglect, or exploitation of vulnerable adults.
OIG believes that data forms the bedrock of oversight and ensures transparency and accountability. Data is an important means of ensuring the identification, reporting, and correction of incidents of abuse and neglect. With Ms. Tinker’s testimony, OIG announced their release of a resource guide (“A Resource Guide for Using Diagnosis Codes in Health Insurance Claims To Help Identify Unreported Abuse or Neglect”), which explains OIG’s approach to using claims data to identify incidents of potential abuse or neglect of vulnerable populations. The guide synthesizes the methodologies that OIG developed in their extensive work on identifying unreported critical incidents, particularly those involving potential abuse or neglect.
The guide includes a flow chart showing key decision points in the process and the detailed lessons that OIG has learned using this approach. OIG encourages CMS, States, providers and other public and private sector entities to use this guide to develop a process tailored to their specific circumstances and apply it to any vulnerable population they deem appropriate. The sources of data could include Medicaid Management Information System claims data, private payor insurance claims data, or similar data sets. Analyzing the data can help identify individual incidents of unreported abuse or neglect, and patterns and trends of abuse or neglect involving specific providers, beneficiaries, or patients who may require immediate intervention to protect their health, safety, and rights. The guide also provides technical information, such as examples of medical diagnosis codes, to assist CMS, States, providers, and others with analyzing claims data to help combat abuse and neglect.
For those organizations who take care of an elderly population, reviewing this guide should be a top priority. You can find the entire guide here.